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m- 





VOLUME XXVIII. 



®^l^ llptcian anlr ^m^m 



A PROFESSIONAL MEDICAL JOURNAL. 



BDITBU BT 

JOHN WILLIAM KEATING, M. I). 

WITH THB COLLABORATION OF 

GBOBGE DOCK, M. D. 

REUBEN PETERSON, Iff. D. 

ALDRED BCX>TT WARTHIN. M. D. 



WALTER ROBERT PARKER, M D. 
FRANK BANGHART WALKER, M. D. 
ALBERT MOORE BARRBTT, M. D. 
R. BISHOP OANFIELD. M. D. 
WILLIAM FLEMING BRBAKET. M. D 
WILLIS SIDNEY ANDERSON, M. D. 
VERNON JUSTIN WILLEY, M. A. 
WILLIAM HORACE MORLEY. M. D. 
IRWIN HOFFMAN NEFF, M. D. 



DEL08 LEONARD PARKER, M. D. 
OYRENUS GARRITT DARLING, M. D. 
DAVID MURRAY COWIE, M. D. 
IRA DEAN LOREE, M. D. 
JAMES FLEMING BREAKEY, M. D. 
CARISTOPHER GREGG PARNALL, M. D. 
GUY UNCOLN KIEFER, M. D. 
MARSHALL LAWRENCE CUSHMAN. M, D. 
LOUIS JACOB HIR8CHMAN, M. D. 
ARTHUR DAVID HOLMES, M. D. 
ROLLAND PARMETER. M. D. 
DAVID INGLIS, M. D. 



JANUARY TO DECEMBER. 



COPYRIGHTED 

Founded bt JOHN WILLIAM KEATING. M. D., January, 1879 

DETROIT AND ANN AKBOR, 

MICHIGAN. 

1900 



AUTHORS. 



Anderson, Willis S., 31, 82, 133, 
225, 26s, 320, 364, 
Akonstam, Noah £., . 
Barhbtt, Albert M., . 
Benn, Walter J., . 
Blodgett, William E., 
BoDiNE, John A., 18, 21, 22, 74, 
Bradley, Ernest B., . 
Breakey, James P., 135, 227, 267, 
Breakey, William F., 
Canfield, R. Bishop, 30, 80, 224, 
Caulkins, John S., 118. 245, 302, 
Chetwood, Charles H., 
Child, Charles G., Jr., 
Collins, Alvah N., . 
Cook, Anna Marion, . 
CowiE, David M., 128, 173, 
Cushman, Marshall L., 363, 
Darling, Cyrenus G., 24. 129, 

Dawbarn, Robert H. M., . 
de Nancrede, Charles B. G., 
Dock, George, 23, 65, 75, 413, 470, 
Edgerton, Joseph I., . 
Freund, Hugo A., 389, 

FuLD, Joseph E., 
Gates, Neil A., . 
Grosh, Lawrence L.. 
HiRSCHMAN, Louis J., 83, 134, 179, 
' 320, 36s, 
Holmes, Arthur D., 27, 77, 133, 
221. 317, 361, 
Keller, Frederick C, 
Keyes, Edward L., Jr., 
Klingmann, Thbophil, 
Knapp, Don D., . 



218, 289, 



219, 
313, 



Page. 

178, 

409» 507 

. 492 

. 563 

• 3" 

97, 400 

125, 127 
. 536 

3^, 510 
.32, 385 

465, 471 

351, 396 
. 74 
. 127 
. 208 
289 
I, 446 

506, 561 

257, 

458, 500 

21 

. 49 

481, 557 
. 170 

446, 469 

20, 217 

. 250 

. 529 
266, 

4", 510 
177, 
406, 504 

. 125 

. 168 
68,558 

. 560 




Kuhn, Charles F., 

Ladinski, Louis J., 

Larkin John H., 

LoREE. Ira D., 28, 78, i 

Lyle, Alexander, 

Lyman, William R., 

Miller, Paul S., 

Morley, William H. 

McGraw, Theodore A 

McKee, Edward S., 

Neff, Irwin H., 35, 62, 84, 136, 

268, 321, 37^. 412, 
Parker, Delos L., 36, 85, 229, 323, 
Parker, Walter R., . 29, 79, 
Parmeter, Rolland, . 
Parnall, Christopher G., 25, 66, 

131, 176, 315. 360, 
Pedersen, Victor C, . 
Peterson, Reuben, 
Porter, Miles F., 
Robinson, Andrew R., 
Signor, Wales Melvin, 
Sinclair, Daniel A., . 
Slocum, George, 
Smithies, Frank, 
SoLis, Jeanne C, 
Taylor, Joseph C, 
Vaughan, Victor C, . 
Walker, Frank Banghart, 76, 

241 
Wallace, James B., 
Warthin, Aldred S., 
WiLLEY, Vernon J., 
Wyman, Hal C, 
Yeomans, Frank C, 



Page. 

. 164 

20 

. 217 

319, 407 
126, 215 

• 255 
. 343 
26, 113 
. 13 
. 494 
228, 

488, 513 
372, 514 
224, 497 
. 404 
. 76, 
403. 502 

214. 215 

461, 499 
. i6q 

145, 433 

47, 316 
. 171 
. 337 
. 467 
. 564 
. 123 
I 

173, 

259, 402 
. 121 
. 544 

193, 512 
. 200 
. 215 



ARTICLES. 



Abdominal section, preoperative treatment 
for, 433. 

Abortion, treatment of, 76. 

Abscess, inferior retropharyngeal, follow- 
ing the removal of adenoids in an adult, 

507. 
Actinomycosis of the neck, 365. 
Adenoids, 255. 

in an adult, inferior retropharyngeal 

abscess following the removal of, 507. 

Alimentary canal, rythmic sounds of the, 

128. 
Anesthesia in rectal surgery, 266. 
in the first stage of labor, 316. 
steiile water, in operative treatment of 
diseases of rectum and anus, 510. 
Anesthetic aid, scopolamine as an, 76. 
Aneurysm, cardiac, 65. 
of the abdominal aorta, a case of, 343. 
of the aorta, 467. 
of the arch of the- aorta, 557. 
Ani, fissure in, and divulsion of the sphinc- 
ter, 179. 
pruritus, treatment of, 365. 
Anus and rectum, sterile water anesthesia 
in operative treatment of diseases of, 
510. 
Aorta, abdominal, aneurysm of the, 343. 

aneurysm of the, 467. 
Appet\dages, diseased, 217. 
Appendicostomy, 411. 
Arhythmias, cardiac, 529. 
Argyrol and protargol as substitutes for 

nitrate of silver, 29. 
Atresia of the bowel, 20. 
Atrophy, infantile, etiology and dietetic 
treatment of, 506. 

B 

Bacteria in scarlatinal and normal throats, 

S08. 
Bier's hyperemia, 506. 
Bile passages and gall-bladder, mortality 

after operations upon the, 402. 
Bowel, atresia of the, 20. 

diagnosis of acute obstruction of, 13. 



Bone, frontal, gumma of the, 215, 
Bowels, locking of the, 83. 
Brain tumors, 84. 
Bronchiectasis, 469. 



Caesarean section, 26. 

Calculi, renal, nephrectomy for hydro- 
nephrosis due to, 499. 
Cancer of the larynx, 265. 
of the skfn, influence of light in produc- 
tion of, 32. 
of the uterus, radical operation for, 25. 
probable hepatic, 560. 
Carcinoma, partial gastrectomy for, 170. 

primary basal-celled, of the appendix, 544. 
Cardiac aneurysm, 65. 

arhythmias, 529. 
Carpus, tuberculosis of the, 214. 
Cell, living, some new conceptions of the, i. 
Cells, ethmoid, orbital and meningeal infec- 
tion from, 82. 
Cerebral tumor, mental symptoms of, 228. 
Cerebrospinal fluid, the, in health and dis- 
ease, 514. 
meningitis, acute pneumococcic, of nasal 

origin, 389. 
meningitis, treatment of, 260. 
Childhood and infancy, the weights of the 

viscera in, 505. 
Cholecystitis, acute infections, 22. 
Chondritis and perichondritis, auricular, 507. 
Chorea, a case of Sydenham's, 558. 

actue, a case of, 68. 
Colic, diagnostic significance of, 173. 
renal, 168. 

renal, artificial, as a valuable means of 
diagnosis, 502. 
Congenital coxa vara, 178. 
Constipation, "spastic," 83. 
Corneal wounds, infection of, by saliva, 264, 
Coxa vara, congenital, 178. 
Cyst, dermoid, 21. 
large ovarian, 127. 
ovarian, with twisted pedicle, 66. 



ARTICLES. 



Cysts, ovarian, situated above the superior 
pelvic strait, complicated by pregnancy, 
403. 

D 

Deformities, and their prevention, 78. 
Dementia paralytica, early ocular signs of, 

136. 

paretic, the clinical aspects of, with special 
reference to differential diagnosis, 488. 

Dermatoses, the unsuspected parasitic origin 
of many, 385. 

Dermoid cyst, 21. 

Diet in epilepsy, 35. 

Digestive and respiratory passages, 133. 

Diphtheria, uncertainties of early diagnosis 
and necessity of early and vigorous 
treatment of, 27. 

Dislocation of humerus, congenital, subacro- 
mial, excision of the head of the hu- 
merus for, 28. 

Duodenum, observations upon the anatomy 
of the, 403. 

Dysmenorrhea, an unusual case of, 121. 

E 

Ear disease, chronic suppurative middle, 

471- 
middle, acute suppuration of, 224. 
middle, suppuration, following intranasal 

operation, 80. 

Editorial : 

Absinthism in comparison with alcohol- 
ism, 473. 

A discovery regarding dead tubercle bacil- 
li, 187. 

An appeal in behalf of blind artisans, 376. 

American Medical Association meeting, 
269. 

Anesthesia without subjective annoyance, 
418. 

A new trypanosome peculiar to tropical 
Africa, 5x6. 

A novel method of reducing infant mor- 
tality, 5x7. 

A purifier for the lacteal product, 418. 

A quick means of preserving milk, 87. 

A record of the heat intensity of radium, 

138. 

A score for radium in surgery, 374. 
A word to the wise, 327. 



Editorial (Continued) : 
Bactericidal action of properly brewed 

tea, 517. 
Baldness ascribed to improper breathing, 

137. 
Baron Takaki's observations on beriberi, 

417. 

Canine disease consequential to coitus, 474. 

Decrees affecting nasal deformity, 517. 

Discord among doctors, 324. 

Disinfecting possibilities of bacteria pecu- 
liar to the intestinal tract, 515. 

Doctor Reed on race suicide, 233. 

Gonorrhea of the female genitalia, 474. 

Herdman, William James, Ph. B., M. D., 
LL. D., 564. 

Hypnotism: its history, nature, and use, 
376, 418, S18, 567. 

Investigations bearing on animal intelli- 
gence, 272. 

Insects as spreaders of infection, 139. 

Lead colic resultant from carbonated 
water, 517. 

Live babes from pregnant subjects of lues, 
139. 

Malaria ascribed to ankylostoma duoden- 
ale, 326. 

Medical classics in medical meeting, 180. 

Medical investigation of the pestiferous 
mosquito, 566. 

Medicine in popular magazines, 138. 

Obligative anaerobes cultivated in the 
presence of oxygen, 566. 

Observations in animal optics, 89. 

Occult therapy in the Ottoman Empire, 

139. 
Pedal characteristics of different peoples, 

41. 
Physicians and philosophers, 42, 90, 234, 

273, 327. 
Physiologic function of the pituitary body, 

41. 

Salt-free diet in scarlet fever, 416. 

Some peculiarities of the spirochaeta pal- 
lida, 417. 

Stoicism of earthquake sufferers, 273. 

Studies in simian vernacular, 88. 

Surgical anesthesia by scopolamin-mor- 
phin, 187. 

The benignity of dessicated tubercle bacil- 
li, 474. 



ARTICLES. 



Editorial (Continued) : 

The catastrophe of the coast, 187. 

The demise of Professor Curie in Paris, 

233. 

The influence of mineral water on mi- 
crobes, 272. 

The mechanical treatment of mal de mer, 

41. 

The new clinic in psychiatry at the Uni- 
versity of Michigan, 37. 

Theories appertaining to appendicitis, 89. 

The Portuguese intematfonal congress of 
physicians, 231. 

The San Francisco earthquake and the 
doctors, 373. 

The scientific achievements of Schaudinn, 

375- 

The Toronto meeting of the British Med- 
ical Association, 413. 

The treatment of cancer with trypsin, 232. 

The treatment of sarcoma with mixed 
toxins, 40. 

The tulase discovery for tuberculosis, 472. 

The ubiquity of cell understanding, 326. 

Tubercle bacilli in phthisic blood, 474. 
Klectricity, static, experience with, 250. 
Encephalitis and poliomyelitis in children, 

361. 

Enuresis, treatment of, 260. 
Epilepsy, diet in, 35. 
Ethics and etiquette, medical, ^82. 
Etiquette and ethics, medical, 482. 
Eye, injuries of, following paraffin injections 
in the nose, 79. 

F 

Faucial tonsils, lymphatic drainage of, 31. 
Feeding, influence of, on infant mortality, 
221. 
in infants, 177. 
Fever, hay, palliatives for, 409. 
Malta, 75. 

scarlet, complications of, 317. 
Fissure in ani, and divulsion of the sphinc- 
ter, 179. 
Fistula, labyrinthine, and paralysis of the 
abducens nerve, complicating a case of 
middle ear suppuration, 224. 
urethral, and prolapsed kidneys, 74. 
Fistulas, treatment of certain, 176. 
Foot, destruction of tissue and nails of, 215. 



Fracture, modern treatment of, 129. 
of the ulna during massage following op- 
eration for Colles' fracture, 125. 
uncommon, 258. 
Furunculosis and mastoiditis in external 
auditory meatus, 561. 

G 

Gall-bladder and bile passages, mortality 
after operations upon the, 402. 

Gangrene of the tonsil, 134. 

Gastrectomy, partial, for carcinoma, 170. 

Gastric surgery and chronic ulcer, 313. 

Genitalis tractus, pathologic physiology of 
the, 145. 

Goitre, exophthalmic, 500. 

Growths, innocent laryngeal, 364. 

Gumma of the frontal bone, 215. 

Gunn, Moses, 49. 

H 

Headache, persistent, unilateral, due to 
nevoid changes in the anterior extrem- 
ity of the middle turbinal bone, 509. 

Heart disease of nephritis, cause and im- 
portance of, 23. 

Hemorrhoids, internal, office treatment of, 
320. 
treatment of, 134. 

Hepatic cancer, probable, 560. 

Hip disease, the conservative treatment of, 
407. 

Humerus, excision of the head of, for con- 
genital subacromial dislocation, 28. 

Hydrocephalus and rachitis treated by radi- 
ant energy, 317. 

Hydronephrosis due to renal calculi, ne- 
phrectomy for, 499. 

Hyperemia, Bier's, 506. 



Indigestion, fat, in infants, 259. 

Infancy and childhood, the weights of the 

viscera in, 505, 
Infant feeding, rural city milk supplies and 

their relation to, 289. 
Infantile atrophy, etiology and dietetic treat- 
ment of, 506. 
paralysis, cerebral and spinal, 361. 
pneumonia, cold-air treatment of, 406. 



ARTICLES. 



Infant mortality, influence of feeding on, 

221. 

Infants, fat indigestion in, 259. 

substitute feeding in, 177. 
Infection of corneal wounds by saliva, 264. 
Infections, acute pelvic, 123. 

cholecystitis, acute, 22. 
Insanity, borderland cases of, 62. 
Intussusception, 126. 



Jaundice, obstructive, Courvoisier's law in 
the differential diagnosis of, 218. 

K 

Kidneys, prolapsed, and urethral fistula, 74. 



Labor, anesthesia in the first stage of, 316. 

conduct of, during second stage, 113. 
La grippe, remarks on, 118. 
Laryngeal growths, the patholog>' of fifty 

cases of innocent, 364. 
Leprosy or syringomyelia, 74. 
Ligaments, round, shortening of the, 315. 
Lipoma, polypoid, of the tongue, 508. 
Longevity, lessons in, 245, 302, 351, 396. 
Lupulin, therapeutics of, 229. 
Luxation, congenital, of the head of the 

radius, 97. 

M 

Mastoid process, necrosis of the, 311. 
Mastoidectomy sinus thrombosis, 30. 
Mastoiditis and furunculosis in external 
auditory meatus, 561. 
with Bier's hyperemia, and acute purulent 
otitis media, treatment of, 506. 
Medical mistakes, 160. 
Medical News : 
A compilation of centenarians, 571. 
A grist of medical graduates, 236. 
American Medicine becomes a monthly, 

140. 
Ann Arbor meeting of nurses' association, 

188. 
Annual meeting of the Roentgen Ray 

Society, 332. 
A physician granted patronymic appella- 
tion, 44. 



Medical News (Continued) : 
Arkansas meeting of Valley Association, 

422. 
Commencement season clinic, 278. 
Dedicatory ceremonies at Harvard Col-" 

lege, 475. 
Life insurance examination fees, 279. 
Prepared food products, 331. 
The Aesculapian grist at Ann Arbor, 382. 
The demise of De Wecker, 44. 
The demise of Doctor Doremus, 189. 
The national medical election, 278. 
The passing of a pioneer Detroit physi- 
cian, 475. 
The Peninsular gathering of physicians, 

278. 
The prevention of "putrifaction," 523. 
The sudden demise of Schaudinn, 331. 
Ziegler, Professor Ernst, 92. 
Minor intelligence, 44, 92, 141, 190, 236, 
282, 332, 382, 424, 475, 523, 572 
Medicolegal questions, 494. 
Meniere's disease and Meniere's symptoms, 

322. 
Meningitis, acute pneumococcic cerebro- 
spinal, of nasal origin, 389. 
cerebrospinal, treatment of. 260. 
Mental diseases, types in, 268. 
Meralgia paresthetica, 267. 
Metatarsalgia, 400. 
Milk supplies, rural city, and their relation 

to infant feeding, 289. 
Morphin poisoning, 171. 
Myasthenia gravis, clinical history and 
postmortem examination of five cases 
of, 371. 
Mycosis occurring in the upper respiratory 
tract, 224. 

Nasal insufficiency, 409. 

obstruction, etiology of, 178. 
Necks, broken, observations on, 319. 
Necrosis of the mastoid process, 311. 
Nephrectomy, 215. 
for hydronephrosis due to renal calculi, 
499. 
Nephritis, heart disease of, cause and im- 
portance of, 23. 
Neuralgia, trigeminal, the surgical treat- 
ment of, 513. 
Nodes, cervical lymph, tuberculosis of the, 
24- 



ARTICLES. 



Nose, paraffin injections in the, injuries of 
the eye following, 79. 
treatment of empyemata of maxillary 
..inus through the, 82. 
Nostrum evil, 85. 

o 

Obituaries : 

Allen, Charles Warren, 335. 
Cook, Emma, 237. 
Curie, Professor, 233. 
De Wecker, Baron, 44. 
Dor emus, Robert Ogden, 189. 
Dunning, Lehman H., 93. 
Herdman, William J., 564. 
Schaudinn, Fritz, 331. 
Skelton, Leonard Lawshe, 141. 
Stewart, Morse, 475. 
Twecdie, Henry, 526. 
Wilson, Jeremiah C, 525. 
Wooster, Samuel R., 94. 
Ziegler, Professor Ernst, 92. 
Obstruction of the bowel, diagnosis of acute, 

13. 

Opsonins, 536. 

Orbit, tumor of, 497. 

Osteitis, tuberculous, of the knee, early op- 
erative treatment of, 261. 

Otitis, chronic purulent, what cases of re- 
quire the radical operation, 408. 

Otitis media, acute purulent, and mastoid- 
itis with Bier's hyperemia, treatment of, 

506. 

Ovarian cysts situated above the superior 
pelvic strait, complicated by pregnancy, 
403. 



Paralysis, cerebral and spinal infantile, 361. 

Paralysis of the abducens nerve, 224. 

Parasitic origin of many dermatoses, 385. 

Paretic dementia, the clinical aspects of, 
with special reference to differential 
diagnosis, 488. 

Parturition, value of time and natural uter- 
ine efforts in, 208. 

Pathlogic physiology of the tractus geni- 
talis, 145. 

Pelvic infections, acute, 123. 
strait, ovarian cysts situated above the 
superior, complicated by pregnancy, 403. 

Perichondritis and chondritis, auricular, 507. 



Peritonitis, bacteriology of, in relation to 
pelvic surgery, 131. 

Physicians, embarking, practical discourse 
to, 241. 

Physiology, pathologic, of the tractus geni- 
talis, 145. 

Pneumonia, infantile, cold-air treatment of, 
406. 
lobar, in infants and children, 133. 

Poisoning, morphin, case of, 171. 

Poliomyelitis and encephalitis in children, 

361. 

Polypoid lipoma of the tongue, 508. 

Pregnancy complicated by ovarian cysts sit- 
uated above the superior pelvic strait, 
403. 
intraligamentary full-term extrauterine, 

404. 
spontaneous rupture of the uterus during, 
20. 

Prostatectomy, mortality after, 259. 

Protargol and argyrol as substitutes for 
nitrate of silver, 29. 

Pruritus ani, treatment of, 365. 

Psychasthenia, 136. 

Psychoses, organic, cytodiagnosis of, 412. 

Pyemia due to middle ear operation, 80. 

Pylorus, hypertrophic stenosis of the, 172. 

R 

Rachitis and hydrocephalus treated by radi- 
ant energy, 316. 

Radiant energy, hydrocephalus and rachitis 
treated by, 317. 

Radius, congenital luxation of the head of, 
97. 

Reading, how a light should be placed for, 
222. 

Rectal surgery, anesthesia in, 266. 

Rectum and anus, sterile water anesthesia 
in operative treatment of diseases of, 
510. 

Renal calculi, nephrectomy for hydronephro- 
sis due to, 499. 
colic, 168. 

colic, artificial, as a valuable means of 
diagnosis, 502. 

Respiratory and superior digestive passages, 
133. 



ARTICLES. 



Reviews : 

Abdominal operations, 480. 

A compound of operative gynecology, 336. 

Acute contagious diseases, 143. 

A laboratory manual of physiological 
chemistry, ig2. 

A manual and atlas of dissection, 432. 

A treatise on diagnostic methods of ex- 
amination, 336. 

A treatise on surgery, 480. 

A text-book on the practice of gynecol- 
ogy, 526. 

Coakley's laryngology, 47. 

Culbreth's materia medica, 528. 

DiflFerential diagnosis and treatment of 
disease, 238. 

Epitome of the practice of medicine, 19a 

Gall-stones and their surgical treatment, 
288. 

Hare's text-book of practical therapeutics, 

48. 

International clinics, 47, 144, 479. 

Nasal sinus surgery with operations on 
nose and throat, 527. 

Operative surgery, 143. 

Practical pediatrics, 96. 

Progressive medicine, 144, 192, 288, 335, 
576. 

Pulmonary tuberculosis, 575. 

Self-poisoning of the individual, 95. 

The physical examination of infantS and 
young children, 96. 

The physician's visiting list for 1907, 576. 

The practitioner's visiting list, 144. 

The prophylaxis and treatment of inter- 
nal diseases, 479. 

The ready reference handbook of diseases 
of the skin, 95. 
Roentgen ray measurement, note on the use 
of the milliamper^meter, 512. 



Sclerosis, multiple, 321. 
Seasickness, a specific for, 323. 
Serum therapy, present status of, 36. 

therapy, progress in, 514. 
Sinusitis, ethmofrontal, three cases of, 320. 
Sinus, maxillary, 82. 

thrombosis, mastoidectomy, 30. 
Skiagraphic technique, 199. 
Skin, cancer of the, 32. 
Sphincter, divulsion of, and fissure in ani, 
179. 



Spirochaeta pallida in syphilis, 227. 
Stenosis, hypertrophic, of the pylorus, 173 
Sterility, the causes of, 360. 
Summer School of the University of Mich- 
igan, 446. 
Surgery, pelvic, bacteriology of peritonitis, 

in relation to, 131. 
Surgical heresy, 18. 

pilgrimage to Arkansas, 200. 
Syphilis, a study of, 366. 

hereditary, influence of paternal inherit- 
ance on, 135. 

spirochaeta pallida in, 227. 

treatment of, 70. 
Syringomyelia or leprosy, 74. 



Tendon transplantation in the forearm, 21. 
Therapeutics of lupulin, 229. 
Therapy, serum, present status of, 36. 

serum, progress in, 514. 
Thrombosis, mastoidectomy sinus, 30. 

sinus and jugular, symptoms and treat- 
ment of, 363. 
Tonsil, gangrene of, 134. 
Tonsillitis and its complications, 164. 
Tonsils, faucial, lymphatic drainage of, 31. 
Tuberculosis among school children, pre- 
vention of, 318. 

in children, origin of, ^^. 

of the carpus, 214. 

of the cervical lymph nodes, 24. 

pulmonary, cocillana as an expectorant in, 
372. 
Tuberculous osteitis of the knee, early op- 
erative treatment of, 261. 
Tumor, cerebral, mental symptoms of, 228. 

of orbit, 497. 
Tumors, brain, 84. 

of the brain, 563. 
Typhoid in children, 504. 

u 

Ulcer, chronic, and gastric surgery, 313. 

Ulna, fracture of, during massage follow- 
ing operation for Colles' fracture, 125. 

Urethral fistula and prolapsed kidneys, 74. 

Urethra, the various gross pathological con- 
ditions of the, as revealed by the 
urethroscope, 492. 

Urine, retention of, 257. 



ARTICLES. 



Urticaria, experimental $tudy of some cases 

of, 510. 
Uterine efforts in parturition, 208. 
Uterus, anterior suspension of the, with 
complications and secondary operation, 
471- 
cancer of, radical operation for, 25. 
spontaneous rupture of, during pregnancy, 
20. 

V 

Varicose veins, 215. 

veins of the lower limb, 22. 
veins, treatment of, 219. 



Veins, varicose, 215. 

varicose, of the lower limb, 22. 

varicose, treatment of, aigi 
Vertigo, aural, 564. 
Viscera, the weights of the, in infancy and 

childhood, 505. 
Visual fields as an aid to diagnosis, 337. 

w 

Warts, simple, treatment of, by internal 

remedies, 267. 
Wounds, corneal, infection of, by saliva, 264. 




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A PROFESSIONAL MEDICAL JOURNAL. 



VOLUME XXVIII. JANUARY, 1906. NUMBER I. 



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ORIGINAL ARTICLES. 



MEMOIRS. 



SOME NEW CONCEPTIONS OF THE LIVING CELL: ITS 

CHEMICAL STRUCTURE AND ITS FUNCTIONS.* 

By victor C. VAUGHAN, Ph.D., M. D., LL.D., Ann Arbor. Michigan. 

mOFBSSOR or HYGIBKB and PHYSIOLOGXCAL CMBMISTRY, DIRBCTOIt OF THB HYCIBNIC ZJkBOBATOBY, AND 
OBAN OP THB PBPABTMBNT OF MBDICINB AND SURGBBY IN THB DNIVBRiMTY OF MICHIGAN. 

Mr. Chancellor, Members of the Faculty, and Students: When I 
received from my friend, your worthy Dean, an invitation to address 
you on this occasion, I delayed my reply for some days, during which 
I seriously debated the question with myself. On the one hand, the 
memory of previous delightful visits to you and the anticipation of 
again being with you urged me to accept ; while the consciousness that 
I was not prepared with an address suitable to the occasion, admonished 
me that the proper thing to do was to decline. However, when I 
recalled the indulgence with which you had received my former efforts, 
the decision was reached, and I now have to offer you my best, fully 
conscious that it is not good enough, and that you will again have 
opportunity to exercise your charity. 

Something more than fifteen years have passed since I had the 
honor of being the guest of the University of Toronto, and I wish to 
say that it is with great pleasure that I have today seen the great 
advance that has been made by this noble institution during that time. 
I first came here to rejoice with my friend. Professor Ramsay Wright, 
on the completion of his biological laboratory, and it is a gratification 
now to see that this laboratory has more than fulfilled the promises 
made at that time. The research .work of its eminent director, of 
Professor McCallum, and others, have carried the name of the Univer- 

* Opening address before the Medical Department of the University of Toronto, 
October 4, 1905. Reproduced by courtesy of The Canadian Journal of Medicine and 
Surgery. 



2 ORIGINAL ARTICLES. 

sity of Toronto around the world. I have had great pleasure in going 
through his new building with Professor Ellis, and in recognizing that 
a chemist, whatever may be the fate of prophets, is not without honor 
in his own country. 

I also rejoice in your splendid new Medical Building, and I envy 
the freshman of today, who comes filled with the earnest intention to do 
his work well, and who, under these favorable conditions, in the well- 
equipped modern laboratories, with such able masters to direct, begins 
the study of the beneficent science of medicine. I was greatly rejoiced 
on reading in the papers this morning of the munificent gifts that have 
been made for the new university hospital. Surely the people of 
Toronto are both wise and generous. He who aids in building a hospi- 
tal, where human suffering may be relieved, is a practical Christian, 
whatever his theological dogma may be. We know not whence we 
came, nor can we name the country to which we journey, but we do 
know that the burdens placed upon the shoulders of those who travel 
along life's highway are not equally distributed, and he who helps his 
fellow-man, who is growing faint, serves his God. There is an old 
legend concerning the origin of the medical profession, which I may, 
I hope, be permitted to repeat. It runs thus : In the olden days when 
the world was yet young, a young Hindoo prince, who had all the world 
could give, entered a temple and, prostrating himself before the image 
of Buddha, besought his god to instruct him in the ways of righteous- 
ness. His prayer ended, he felt upon his shoulder a hand as light as 
that of a child, and a voice as sweet as that of an angel asked, "Wouldst 
thou most acceptably serve thy God? If this be thy desire, go forth 
and serve thy fellow-men," and the prince went forth, the first physician 
to walk among men. 

My visit is not without its tinge of sadness. I miss several faces 
that were familiar to this campus fifteen years ago. Of two of these 
I must be permitted to say a few words. There was a sweet-mannefed 
man, gentle in voice and kind even in reprimand, an eminent ethnolo- 
gist, an able historian, whose memory has always been to me a charming 
recollection. Such a man was Sir Daniel Wilson. The other was a 
professional brother, whose life was a help to those of his own genera- 
tion and an inspiration to the young. Such a man was the late Doctor 
Graham, of this city and university. 

I have decided to briefly discuss "Some New Conceptions of the 
Living Cell : Its Chemical Structure and Its Functions." No one can 
question the importance of this subject, involving, as it does, biological 
problems, which lie at the foundation of all our conceptions and theories 
concerning cellular life and cellular activity. 

To start ab initio, the cell is made up of matter, and the newer 
views on matter must be taken into consideration in formulating a 
conception of the cell. When matter becomes endowed with life it does 
not cease to be matter ; it does not lose ijs inherent properties ; it is not 
released from the laws that govern its structure, its attractions, and its 



CONCEPTIONS OF THE LIVING CELL. 3 

motions. In studying the organized cell of living thing, whether vege- 
table or animal, it should always be borne in mind that it is material in 
composition and subject to the fundamental laws that govern matter, 
and possessed of those properties essential to matter. In order that 
this point, so essential to a proper understanding of the subject, should 
be thoroughly appreciated, it may be best to recall some of the prop- 
erties of matter as taught by the most advanced science of the day. 

Tait says : "Matter is that which can be perceived by the senses, or 
is that which can be acted upon by or can exert force." Since force is 
the restilt of motion, we may say that anything and everything that 
moves or can be moved, or whose position in space may be changed is 
matter. There are many forms of matter that cannot be seen or felt, 
and can be recognized only by their motions. 

Matter is indestructible; it may be successively solid, liquid and 
gas, but in undergoing these changes it neither gains nor loses. It has 
always been, and it always will be. It is without beginning and will be 
without end. Matter consists of infinitely small particles, called atoms. 
According to tlje computation of Lord Kelvin, the diameter of an atom 
is not greater than a 1-50,000,000 of an inch ; however, all atoms are not 
of the same size or weight. When like atoms combine they form 
chemical elements, of which about seventy are known. The hydrc^en 
atom is the lightest of all known elements, and it therefore is taken 
as the base or standard in the determination of atomic weights. When 
unlike atoms combine, chemical compounds are formed, and the number 
of these is beyond computation. It was supposed, until the discovery 
and study of radium, that one chemical element is never converted into 
another, and consequently that the number of kinds of atoms is fixed 
and unchangeable. However, it has been found that the ;ir-rays of 
radium consist of most minute particles, which, when confined in glass, 
condense and form another element, helium. With this demonstration 
of the formation of one element from another it is within the range 
of sanity to suppose that all the elements have been developed from 
a primordial ancestor, probably from the universal ether which per- 
vades all space.. Nothing has been created; everything has grown. 
Even silver, iron, and other metals came into existence by being cast 
off from some common ancestral element. The atomic weight of 
radium is 225 and that of helium 2.02. It would seem from this that 
an atom of the former breaks up into about one hundred atoms of the 
latter, and in this way a new element is bom, although in this case it 
is probable that the mother atom is split into two or more kinds. It 
will be seen from this that even atoms may be split up. Indeed, there 
are reasons for believing that the hydrogen atom consists of a nuclear 
ion about which some seven hundred particles or electrons revolve, and 
an atom of mercury is believed to consist of not less than one hundred 
thousand electrons. Atoms and electrons are in constant motion, and 
so small are they that the distances between them may be relatively 
as great as those between the planets of the solar system. The living 



4 ORIGINAL ARTICLES. 

cell is c(»iiposed of molecules, made up of atoms, composed of electrons 
that are in constant and systematic motion, and may be compared to a 
group of stars with attendant suns, each of which is surrounded by its 
own planets. A molecule of albumin is of like composition. 

Another property of matter is that it is gravitative. Every particle 
of matter attracts every other particle. When this attraction is mani- 
fest between masses it is called gravitation; between molecules, it is 
called cohesion or adhesion, as the molecules held together are alike 
or unlike; between atoms it is known as chemical affinity or chemism. 

Still another property of matter is inertia, by which term we indi- 
cate the inability of matter to change either its rate or direction of 
motion without being acted upon by other matter. It is of great 
importance that this property of matter be held in mind in the study 
of cellular chemistry, and the proper mental picture of a cell molecule 
represents each of the atoms in the molecule, and each electron in each 
atom moving each about its centre and each at a definite rate. If 
such a cell molecule could be cut off permanently from the disturbing 
influence of other matter, its atoms and electrons would continue the 
same motions, unchanged in direction or rate, throughout eternity, 
but, as we shall later see, it would be impossible for living matter to 
continue to live apart from other matter. Within the living cell 
molecule change in number, kind, and arrangement of atoms is con- 
stant ; and the direction ^nd rate of the motion of the atoms are also 
susceptible to the influence of other matter and are of constant 
occurrence. Whole groups of atoms are physiologically being dropped 
from the cellular molecule and being replaced by other groups split 
oflF from the pabulum upon which the cell feeds. In this way the 
cell renews itself and keeps itself supplied with energy. 

Some of the most noted physicists are inclined to the belief that 
matter is made up of electric charges, but recognize that this is not a 
demonstrated fact as yet, and speak with caution. Lodge says: 
"There may possibly be two diflFerent kinds of inertia, which exactly 
simulate each other, one electrical and the other material; and those 
who hold this as a reasonable possibility are careful to speak of electrons 
as 'corpuscles,' meaning charged particles of matter of extremely small 
size, much smaller than an atom, consisting of a definite electric charge 
and an unknown material nucleus; which nucleus, as they recognize, 
but have not yet finally proved, may quite possibly be zero." 

The only essential and constant difference between living and 
nonliving matter is that within the molecules of the former there is 
constant metabolism, while in the latter no such process occurs. We 
are to conceive of the living molecule as made up of numerous atoms 
and each atom surrounded by its electrons: atoms and electrons in 
ceaseless motion, and groups of atoms being constantly cast out of 
the molecule and replaced by new groups split off from matter outside 
the molecule. As soon as a molecule becomes the seat of assimilation 
and excretion, it is no longer dead, it lives. As a result of assimilation 



CONCEPTIONS OF THE LIVING CELL. 5 

it acquires the property of building up its own tissue ; then polymeriza- 
tion follows and reproduction in its simplest form begins. The one 
phenomenon always manifested by living matter, and never exhibited 
by nonliving matter, is metabolism. Verworm says: "Vital motion, 
metabolism, is a complex motion very strongly characterizing the living 
organism ; it consists in the continual self-decomposition of living sub- 
stance, the giving off to the outside of the decomposition products, 
and, in return, the taking in from the outside of certain substances 
which give to the organism the material with which to regenerate 
itself and grow by the formation of similar groups of atoms, that is, 
by polymerization. This is characteristic of all living substance." 

I have promised to give you some of the new conceptions of the 
living cell, and yet I must admit that Aristotle apparently recognized 
that metabolism is the one characteristic of living matter, for he says : 
"Life is the assemblage of the operations of nutrition, growth and 
destruction." Of course, this Greek philosopher did not know about 
cells, molecules, atoms and electrons what is today known, but it must 
be acknowledged that he had a clear conception of the most essential 
characteristics of living matter. Herbert Spencer has given three 
definitions of life, and either may be applied to the conception which 
I am trying to present to you. The first is : "Life is the coordination 
of actions." The coordination between assimilation and excretion is 
certainly essential to life, and failure of this coordination leads to 
death. The second is probably the best definition of life ever given, 
and fits our conception perfectly. It is: "Life is the definite com- 
bination of heterogeneous changes, both simultaneous and successive, 
in correspondence with external coexistences and sequences." The 
third is practically the same as the second, expressed in simpler terms, 
but in my opinion not so satisfactorily. It reads: "Life is the con- 
tinuous adjustment of internal relations to external relations." Matter 
is alive when it feeds and excretes. Crystals grow and in a sense they 
multiply, but their growth is not intramolecular, it is by accretion. 
The living molecule not only absorbs, it assimilates. It chemically 
alters what it absorbs. The atomic groups taken into the living mole- 
cule enter into new combinations. The living molecule is not stable, 
but is highly labile. Its composition is never constant and it is never 
in a condition of equilibrium. There is a constant reaction between 
the living molecule and other molecules. Apart from other matter 
it could not exist. There is a constant interchange of atones between 
it and other molecules. A condition best designated as latent life 
may exist without interchange of atoms between molecules. This is 
seen in spores, s^eds and ova. Matter existing in this form may be 
awakened into activity by proper stimuli; active life begins with the 
interchange of atoms. 

Why is there this constant atomic group Interchange between the 
living molecule and outside matter? It is for the purpose of supplying 
the living molecule with energy. Allen has so ably expressed this 



6 ORIGINAL ARTICLES. 

fact that I make the following quotation: "The most prominent and 
perhaps most fundamental phenomenon of life is what may be described 
as the ettergy traffic or 'the function of trading in energy. The chief 
physical function of living matter seems to consist in absorbing energy, 
storing it in a higher potential state, and afterwards partially expending 
it in the kinetic or active form. We find in living matter a peculiar 
proneness to change its composition under the stimulus of slight 
changes in the energy-equilibrium between itself and its surroundings, 
energy being readily absorbed and readily dispersed. The absorption 
of energy coincides with deoxidation and the building of large mole- 
cules ; conversely the dispersion of energy coincides with oxidation and 
the disruption of the large molecules. The building of these large 
molecules is always accomplished by slow steps ; but when formed, the 
said molecules are very unstable, irritable, or in modern phrase, labile. 
They may break down by degrees in some instances; in others their 
structure may be so precarious as to collapse on the slightest disturb- 
ance." 

"The lability of such a molecule may be compared to that of a 
house of cards, which can be taken to pieces, card by card, or may 
collapse at once. But the word lability is applied, not only to 
d^-structive, but also to con-structive instability. The molecules of 
living substance are prone to constructive as well as destructive 
changes; but, as in the house of cards, the constructive changes are 
the most gradual; and as the structure grows more complex, con- 
struction becomes more difficult, and collapse is more imminent. It 
should be distinctly understood, however, that it is not the mere size 
of the molecules that makes them labile, but rather the manner in 
which they are linked together, and the amount of potential energy 
which is included in the molecule." 

It is probable that in the absorption of energy by the living mole- 
cule, oxygen is relieved from its combination with carbon or hydrogen 
and is attached to nitrogen, while in the liberation of energy the 
reverse takes place. Nitrogen and phosphorus, sometimes with iron 
and possibly manganese, seem to be, as it were, the master elements 
within the living molecule. It is by virtue of their chemism that groups 
are torn from extracellular matter, taken into the living molecule and 
assimilated by an atomic rearrangement; and furthermore, it is on 
account of the lability of the compound thus formed that potential 
energy is converted into kinetic and cell work is accomplished. 

The question of the origin of life on this world has been ably dis- 
cussed by eminent chemists, physicists and biologists. The cosmozoa 
theory proposed by Richter holds that cellular life has always existed, 
and has been transferred from one planet to another by meteors and 
cosmic dust. Richter says: ''Omne vivum ab aeternitate e cellula." 
Helmholtz and Lord Kelvin have pronounced this theory not unscien- 
tific, and the former makes the following statement : "Meteoric stones 
sometimes contain hydrocarbon compounds; the intrinsic light of the 



CONCEPTIONS OF THE LIVING CELL. 7 

heads of comets shows a spectrum that is very similar to that of the 
incandescent electric light in gases containing hydrocarbon. But 
carbon is the characteristic element of the organic compounds, of which 
living bodies are composed. Who can say whether these bodies that 
swarm everywhere through space do not spread also the germs of life 
whenever a new world has become capable of affording a dwelling- 
place to organic creatures? And this life we mig^t, perhaps, have 
reason to regard as even allied to our own in germ, however various 
may be the forms in which it might adapt itself to the conditions of its 
new dwelling-place." 

Preyer objects to the cosmozoa theory that it only sets the question 
back to, How did life originate in the universe : and Helmholtz says : 
"The true alternative is evident ; organic life has either begun to exist 
at some one time, or has existed from eternity." 

Pfliiger's theory of the origin of life is the most scientific yet 
proposed. He argues that living proteid differs from dead proteid by 
the existence in the former of a cyanogen radicle. He says : "In the 
formation of cell substance, that is, of living proteid out of food proteid, 
a change of the latter takes place, the atoms of nitrogen going into a 
cyanogen-like relation with the atoms of carbon, probably with the 
absorption of considerable heat." Pfliiger calls attention to the resem- 
blances between cyanic acid, HCNO, and living proteid. Both easily 
polymerise, the living proteid growing and the cyanic acid forming 
the polymeric cynamelid HnOwNnOw. Both yield urea on dissocia- 
tion; both are liquid and transparent at low temperature, and both 
coagulate at higher temperature. Pfliiger concludes that the beginning 
of life depended upon the formation of cyanogen, and then he reminds 
us that cyanogen and its compounds are produced only at incandescent 
heat. He summarizes as follows: "Accordingly, I would say that 
the first proteid to arise was living matter, endowed in all its radicles 
with the property of vigorously attracting similar constituents, adding 
them chemically to its molecule, and thus growing ad infinitum. 
According to this idea, living proteid does not need to have a constant 
molecular weight; it is a huge molecule undergoing constant, never- 
ending formation and constant decomposition, and probably behaves 
towards the living chemical molecules as the sun behaves towards 
small meteors."* 

It will be seen that according to Pfliiger life is a molecular phe- 
nomenon, and it seems to be that this must be true. Nonliving matter, 
whether it be inorganic or organic, is relatively stable intramolecularly, 
while living matter is never stable within its molecule, which is con- 
stantly casting out and as constantly absorbing atomic groups. It 
assimilates and it excretes, and these phenomena are its essentials. 
Deprive the living molecule of food, and it dies ; prevent its excretion, 
and it dies. Reaction between the living molecule and outside matter 
is constant, and is necessary to the continuance of life. The fact that 

"The different theories of the origin of life are ably discussed by Verworm in his 
"General Physiology." 



8 ORIGINAL ARTICLES. 

life resides in the molecule is, as I have stated, taught in Pfliiger's 
theory. It is also recognized by Allen, who, in speaking of living 
proteid, says: "It is a molecule of enormous size, and (so far as the 
dynamic elements are concerned) its various groups are linked together 
by many nitrogen atoms, but not in a chain. It is not a proteid, a 
cyan compound, an amid, an amine, nor an alkaloid, but something 
that can yield some of them during life and others at its death. Death 
consists in the relaxation of the strained relationship of the nitrogen 
to the rest of the molecule. When thus 'the silver cord is loosened/ 
the relaxed groups fall into a state of repose. Most of these groups 
are proteids in which the N is peripheral, triad and unoxidized, having 
yielded its O to some other element. If, however, such a proteid 
molecule be applied to a living cell, it can be linked on again by its N, 
which thus once more becomes central." 

In his very interesting monograph on the "Biogen Hypothesis," 
Verworm objects to saying that a molecule lives. He states that it is 
illogical. "A living thing is only that which demonstrates the phe- 
nomenon of life — something that changes itself. A molecule of a 
given compound, so long as it remains unchanged, cannot be said to 
be living." Then, in order not to speak of living molecules, he intro- 
duces the term "biogen molecule," instead of the living molecule. 
Surely this is a distinction without a difference. I certainly agree that 
a molecule of a germ compound, so long as it remains unchanged, 
cannot be said to be living, but the point is that living molecules do not 
remain unchanged. When life is latent, as it is in seeds and spores, 
the molecules cannot be said to be alive ; but when placed under suitable 
conditions, then the change between atomic groups in the molecule 
and the external food substance begins, and life first manifests itself. 
However, it matters but little, I suppose, whether we speak of living 
molecules or biogen molecules. 

That life resides within the molecule and that metabolic processes 
are intramolecular, are shown by numerous investigations, some of the 
most important of which may be briefly stated as follows : 

(i) As long ago as 1867 it was shown by Hermann, in his studies 
on the metabolism of isolated muscle, that the carbonic acid and lactic 
acid that are formed by muscular contraction result from the action 
of intramolecular or combined oxygen. This was demonstrated by 
the fact that when a muscle was freed from all its uncombined oxygen 
under an air pump and then caused to contract in an oxygen-free 
medium, it gives off carbonic and lactic acids. Contraction, a vital 
muscle phenomenon, is thus shown to result from intramolecular 
changes. 

(2) In 1875, Pfliiger kept a frog at a temperature of a few degrees 
above zero in an atmosphere free from oxygen for twenty-five hours, 
and found that during that time the animal continued to give off car- 
bonic acid. From this Pfliiger concluded that the living content of the 
organism consists of proteid, which he designates "living proteid," in 



CONCEPTIONS OF THE LIVING CELL. 9 

contradistinction to dead proteid, and that the carbonic acid gas results 
from the decomposition of a labile proteid molecule, the nitrogehous 
constituents of which are capable, with the help of the fats and car- 
bohydrates of the food, to regenerate "the living proteid molecule." 

(3) It has been shown by recent research in my own laboratory 
that both the toxin and the carbohydrate of the cell of the colon bacillus 
are held in chemical combination with other constituents of the cell. 
This microorganism will grow in a medium which contains organic 
nitrogen, as amino compound only, and with this nitrogen and inor- 
ganic salts as its sole food, it builds up by synthetical process a complex 
glyco-nucleo-proteid, forming a large molecule which contains as 
atomic groups, pentose, nuclein bases, amino and diamino compounds. 
These constituents are held chemically in the cell. They cannot be 
washed out by physical solvents, and can be isolated only by chemically 
breaking down the cell molecule. 

Besides the above-mentioned experimental data showing that life 
manifests itself by intramolecular reaction, the following general con- 
siderations indicate the same thing: 

(a) In taking its food the cell, whether it be vegetable or animal, 
whether it be that of a unicellular or that of a multicellular organism, 
manifests a selective action which can be best explained — indeed, I 
might say, can only be explained — on the ground that it is due to 
chemical affinity. Mass and molecular attractions are not specific, 
while atomic attraction, or chemical affinity, as it is usually designated, 
is specific, or at least selective. This fact, as is well known, is the 
basis of the side chain theory of Ehrlich, who, upon this principle, 
explains the nutrition of cells, the action of many therapeutical agents 
and the production and action of antitoxins. It is well known that 
certain poisons have a selective action for certain tissues, and this 
means that the chemical affinity between the poison and the con- 
stituents of certain cells is greater than that between this poison and 
other cells. If pharmacology and toxicology ever become exact 
sciences it will be, most probably, through investigations directed along 
this line. 

(b) The fact that the secretions of cells are specific is a strong 
argument for the theory that action on the pabulum upon which they 
feed is intramolecular. The liver cells produce bile pigments and 
acids, each of the digestive fluids elaborates its specific products, the 
specific secretions of the adrenals and the thyroid gland have been 
studied and are now largely and successfully employed therapeutically. 
And still all these organs are supplied with the same blood and lymph. 
Certainly the only possible explanation for these well-established facts 
is that of a chemical reaction, or an intramolecular reaction, between the 
cells and the constituents of the substances with which they are brought 
into contact. 

While other arguments might be adduced to show that metabolic 
processes, the only phenomena with which we are acquainted, that are 
characteristic of all living matter and which do not occur in dead mat- 



10 ORIGINAL ARTICLES. 

ter, are due to intramolecular reactions, it seems to me that those 
alr&idy given are sufficient to establish my thesis, that is, life is mole- 
cular. 

If I have made good my contention so far, it follows that life begins 
with the first molecule that is endowed with the capability of growth 
and reproduction. The life of such a molecule would depend upon its 
continued reaction with matter outside of itself, or, in other words, it 
must feed; and reproduction in its simplest form would depend upon 
polymerization. In this way the wonderful experiments of Loeb upon 
the artificial fertilization of certain ova are easily explained. The ovum 
is not alive; it possesses only latent life, and when acted upon by 
certain stimuli it begins active life. This stimulus may be a spermata- 
zoon or some inorganic salt in a certain definite strength of solution. 

If life be molecular, it is possible that its lowest manifestations are 
without form. They may be infinitely small, and it is not beyond the 
range of possibility that they may exist as solids, liquids, or gases. 

Spontaneous generation has never been proved to be impossible; 
indeed, it will not be eas^ to disprove spontaneous generation. I agree 
with Naegele in the following statement: "One fact — ^that in or- 
ganisms inorganic substance becomes organic substance, and that the 
organic returns completely to the inorganic — is sufficient to enable 
us to deduce by means of the law of causation the spontaneous origin 
of organic nature from inorganic. ... If in the physical world all 
things stand in causal connection with one another, if all phenomena 
proceed along natural paths, then organisms, which build themselves 
up from and finally disintegrate into the substances of which inorganic 
nature consists, must have originated primitively from inorganic com- 
pounds. To deny spontaneous generation is to proclaim a miracle." 

The experiments of Tindall, Pasteur, and others, which were sup- 
posed to completely and forever overthrow the doctrine of spontaneous 
generation, in my humble opinion, did no such thing. They simply 
demonstrated that bacteria do not spontaneously generate in meat 
infusions and similar media, nothing more. Now, it seems to me that 
bacteria, which we frequently call the lowest forms of life, are by no 
means certainly entitled to this distinction. They may be the lowest 
forms with which we are acquainted, the smallest living things that 
we can see with our best microscopes. But chemically they are com- 
posed of extremely complex molecules, as has been shown by recent 
research in my laboratory. As I have already stated, the cell of the 
colon bacillus consists of a highly complex glyco-nucleo-proteid, yield- 
ing, on chemical disintegration, a carbohydrate, pentose, the nuclein 
bases, the monamino and diamino bodies, as tyrosin, leucin, lysin and 
arginin. In other words, chemically the colon molecule is quite as 
complex as that of the lower grade tissues in man. Now, if there has 
been a chemical, as well as a morphological, evolution, the colon bacillus 
is not the lowest form of life; indeed, it must be far removed from the 
first molecule that manifested metabolic activity. 



CONCEPTIONS OF THE LIVING CELL. 11 

The following quotation from Nussbaum, as given by Loeb, shows 
that the biologist recognizes that the cell is not the unit of life : "The 
cell is not the ultimate physiologic unit, even though it must remain 
such for the morpholc^st. We are, however, not able to tell how far 
the divisibility of a cell goes, and how we can determine the limit 
theoretically. Yet for the present it will be well not to apply to living 
matter the conceptions of atoms and molecules, which are well defined 
in physical chemistry. The notion, micella, introduced by Naegele, 
might also lead to difficulties, as the properties of living matter are 
based upon both nuclein and protoplasm. . . . The cell, conse- 
quently, represents a multiple of individuals." 

Pfliiger has shown that the egg, which has been thought to be a 
unit, can give rise to many individuals, and Loeb states that his own 
experiments, as well as those of Driesch, confirm this finding. 

It is highly probable that the lowest forms of life cannot feed upon 
proteids. This is true of the yeast cell. These cells grow rapidly 
when placed in a solution of sugar and nitrates, but proteids must be 
broken up by putrefactive bacteria before the yeast germs can feed upon 
them. Indeed, many of the cells of the body of man cannot feed upon 
proteids, which must be split up by the digestive enzymes into much 
smaller and simpler groups before the cell molecules can assimilate 
them. Even the carbohydrate, starch, must be hydrated before it can 
become a source of energy in muscle. Proteid solutions injected into 
the blood of man are poisonous, but the same substance, after being 
properly split up, is an essential cell food. There are weighty reasons 
for believing that proteid is not produced by the lowest forms of life. 
However, as proteid, or cellular life, is the only form of life that we 
know, it would be quite useless to attempt to go further along this 
line. 

I have probably said enough concerning spontaneous generation 
to bring down upon myself the anathemas of the orthodox in science, 
and since my opinion on this subject does not have any essential rela- 
tion to the important thesis of this paper, I will leave this point without 
further discussion. 

If the characteristic phenomena of life are due to intramolecular 
reactions, we must conceive the living cell, whether it belong high or 
low in the scale of development, as consisting in its essential or vital 
part of a chemical compound made up of complex molecules, composed 
of atoms, each surrounded by its electrons, all in motion, and with a 
constant absorption of atomic groups from other molecules, and whh 
a like constant casting off of atomic groups. 

This molecule feeds by splitting off such groups as it may need 
from the pabulum within its reach, or it may absorb whole molecules, 
at the same time rearranging the atoms and making them a part of 
itself. 

When, in ordinary physiological function, a portion of this molecule, 
which we may designate its chemical nucleus, remains undisturbed and 



12 ORIGINAL ARTICLES. 

regenerates the whole, supplying its waste by the absorption of new 
matter. 

Cellular assimilation consists in properly locating the recently 
acquired groups within the molecule. 

Certain cell molecules, under proper stimuli, rearrange their atomic 
grouping, polymerise, and thus multiply. This multiplication may be 
physiolc^cal or pathological. Rapid proliferation may tend to inability 
to function or to react with the food supply, and consequently destroy 
the molecule or lead to the death of the cell. 

With this conception of a living cell, its secretions consist of the 
atomic groups cast out as a result of its reactions with external matter, 
and as the cells of different organs are unlike in their chemical com- 
position, it follows that the secretions are specific. Outside the body 
hemoglobin breaks up, or may be broken up, chemically, into hematin 
and globulin. In this case the colored split product contains the iron. 
But the liver cells produce from hemoglobin bilirubin and an iron 
containing proteid. In this inaction the line of cleavage is quite dif- 
ferent from that followed in the ordinary decomposition of hemoglobin. 
The secretions of some cells enter into a more or less energetic reaction 
with certain extra-cellular compounds with which they come in con- 
tact. This is true of the digestive enzymes. Other secretions appar- 
ently are made for the purpose of reacting with or at least affecting 
the reactions of the molecules of other cells. This seems to be true of 
some at least of the so-called internal secretions, such as those of the 
thyroid and adrenals. 

A most important group of cellular secretions is made up of the 
ferments of enzymes. Without going into the history of the theories 
that have been advanced concerning the nature of these bodies, it seems 
to me that we are no longer justified in speaking of "organized and 
unorganized" ferments. All the ferments are cellular products. The 
work of Buchner on the ferment of the yeast plant seems to be posi- 
tively convincing on this point. Oppenheimer has defined a ferment 
in a manner that seems to me to be quite in accord with the latest and 
best experimental investigation. His definition is as follows : "A fer- 
ment is a catalytically-acting substance which is produced by living 
cells, to which it is more or less firmly bound, whilst its action is not 
associated with the vital processes of the cells (which produce it) ; 
ferments are capable of inaugurating chemical processes which take 
place spontaneously (without the presence of the ferments), but pro- 
ceed much more slowly. In this process the ferment, itself, remains 
unchanged. Ferment action is specific, that is, each ferment manifests 
its activity only on substances of certain structural and stereochemical 
arrangement." 

I am conscious that my translation of this definition is not altogether 
satisfactory, and in order to give a more exact interpretation of it, 
as I understand it, I offer the following explanatory statements: 

( I ) Every ferment is a cellular product ; it is a cellular secretion ; 



ACUTE OBSTRUCTION OF THE BOWEL. IS 

a substance of definite chemical composition formed by the rearrange- 
ment of the atomic groups within the cellular molecule. 

(2) The action of the ferment, while it is determined by the cell 
which produces it, is not concerned in the "energy traffic" constantly 
going on between the molecules of the cell which produced it and other 
molecules external to this cell. With our present limited knowledge 
of the chemistry of the cell molecule it is impossible, in many cases at 
least, to distinguish between the chemical reactions resulting from cell 
metabolism and those due to ferments. I am inclined to the opinion 
that more exact knowledge will show that the autolytic changes that 
take place in many cells after death, and which have furnished the 
theme of so many papers recently, will be found not to be due to fer- 
ments at all, but to the cessation of metabolic reaction. 

(3) The function of a ferment is to hasten chemical reactions which 
take place, but much more slowly, without the presence of the ferment. 
It seems to me that a clear conception of this point gives one a key to 
the action of ferments in general. I have, in the first part of this 
paper, called attention to the fact that inertia is a universal property of 
matter; that the direction and rate of movement in matter can not 
be altered spontaneously. A ferment is a substance which by its 
presence changes the tempo of chemical reaction. I am fully aware 
that this does not explain why the ferment acts by its presence, but 
it is worth much to have a conception of hozv it acts, provided, of course, 
that this conception be correct. Furthermore, it must be admitted that 
the modus operandi of ferments is still beyond our ken. Some think 
that certain atoms or atomic groups are detached from one of the sub- 
stances, combine with the ferment, and then are passed on to the other 
substance. On this supposition the ferment does enter into the reac- 
tion, but is constantly regenerated. Others hold that the ferment 
combines with the fermentable substance, making its molecule so labile 
that it falls to pieces, and that in the dissociation the ferment is again 
set free. There are weighty objections to either of these theories, but 
time will not permit me to state them in this paper, which is intended 
to be suggestive rather than exhaustive. 



ON THE DIAGNOSIS OF ACUTE OBSTRUCTION OF 
THE BOWEL.* 

By THEODORE A. McGRAW. A. B., M. D., LL. D.. Detroit, Michigan. 

I OP SVBGBRY AND CLINICAL SURGBRT IN THB OBTROIT COLLBGB OF MBDICINB. 



Disorders, which increase rapidly in virulence and if unrelieved 

cause speedy death, demand early and correct diagnosis and positive 

treatment. Of such, there are none which are more urgent than acute 

intestinal obstructions, and none in which hesitation and delay are more 

disastrous. The physician who ponders too long in these cases over 

the diagnosis, comes to a decision too late for his patient's salvation. 

*Read at the Add Arbor meetitifB^ of the First Concilor District Medical 
Society, December, 22, 1905. 



14 ORIGINAL ARTICLES. 

Schlange divides intestinal obstructions into two classes, the dynamic 
and the mechanical. The dynamic are paralytic conditions which are 
usually secondary to other troubles. They may be caused by nervous 
shock. I met with this form once in a case of acute pancreatitis, which 
I operated on in Monroe with Doctor Southworth. A man of forty- 
five years was seized with a violent pain in the epigastrium and fell at 
once into a collapse. I saw him twenty-four hours later. He had then 
rallied s(»newhat but was suffering great pain in the abdomen. There 
was great distension and the abdomen was very sore. I diagnosticated 
the trouble as perforation by a gastric ulcer and expected to find the 
intestines highly inflamed. On opening the abdomen, however, I 
found them of normal color and appearance but highly distended with 
gas. On lifting up the stomach an abscess was discovered in the tail 
of the pancreas. 

These cases are uncommon. The usual cause of dynamic obstruc- 
tion is inflammation of the peritoneum of which the type is a sup- 
purative appendicitis. The treatment of these cases is that proper for 
the inflammation which causes them. Their symptoms, pathology and 
treatment have been the subject of innumerable treatises and discus- 
sions and are familiar to all intelligent practitioners. I shall not, there- 
fore, discuss them in this paper but confine my remarks to obstructions 
caused by mechanical forces. These include all cases of hernia, vol- 
vulus and intussusception, and of obstructions caused by inflammatory 
bands, by adherent diverticulums, by tumors and cancers, by faults in 
development and by fecal impactions and foreign bodies. 

Mechanical obstructions may be divided into two classes: those 
which suddenly and completely occlude a gut and those which cause 
only a partial stenosis of slow development. This is a highly practical 
division, inasmuch as the two classes differ much in symptoms and 
demand different treatment. 

It is the obstructions due to the various forms of strangulation and 
to intussusception which are most speedily fatal and which, never- 
theless, if operated on early, offer the best results. In many cases 
an operation in the first twelve hours after the seizure would have little 
more danger than an exploratory incision, while operations after the 
lapse of forty-eight hours are almost always followed by death. The 
symptoms caused by all these various forms of acute mechanical 
obstruction are uniformly the same, modified only by the seat of the 
obstruction, as it occurs in the large or small intestine, and by the 
idiosyncracies of the patient. There is first a sudden and violent pain 
in the abdomen, followed by nervous shock and vomiting. There is 
in the first twelve hours, as a rule, but little abdominal tenderness and 
the patient rarely objects to the manipulation of the abdomen by the 
surgeon. Almost immediately, however, there begins a perceptible 
distension of the abdomen which, in the very beginning, is localized 
and confined to the affected coil but soon involves the intestines above 
it. In persons with thin abdominal walls, the coil which is the seat 



ACUTE OBSTRUCTION OF THE BOWEL. 15 

of the injury may be discovered as a projecting spot on the abdomen. 
It is distended and paralyzed and will not contract under any stimulus. 
Vomiting does not relieve the nausea, and continues without cessation. 
The bowels are obsttnately constipated and do not respond to pur- 
gatives but may discharge such of their contents as are contained in 
the part below the constriction. When, as sometimes happens, the 
affected coil is in the pelvis, there may be no distension of the abdomen 
but the swollen intestine may be felt by rectal or vaginal examination. 
This was the case in a boy upon whom I operated on the seventh of this 
month. He had been ill over three days when he was brought to the 
hospital enormously distended. His physician told me that the abdo- 
men during the first two days was flat and unsensative. I found a 
black and gangrenous volvulus of large size, which I fished out of the 
pelvis. In these cases a careful examination of the pelvic cavity 
through the vagina or rectum should never be omitted. 

The course of the distension in obstruction has an important bearing 
on the diagnosis. The abdomen is not suddenly inflated as in severe 
acute enteritis or peritonitis ; aflFecting at first only one coil, the swelling 
is for some hours localized and moderate, and only gradually extends 
to the gut which lies above the constriction. In the last stages, how- 
ever, the whole abdomen may become swollen to its utmost capacity. 
In fat people it is much more difficult to map out the affected coils. 

It is characteristic of obstruction in the early stages that the result- 
ing swelling is comparatively free from soreness. I have, indeed, seen 
several patients in whom this freedom from tenderness on pressure 
continued into the second and third day, even though they were suffer- * 
ing extreme pain. In fact, I have come to look upon the disproportion 
between the pain of obstruction and the soreness of the abdomen as 
pathognomonic of the disorder. A patient will from the very begin- 
ning complain bitterly of pain but will, without flinching, allow the 
surgeon to thoroughly manipulate and examine the abdomen. There 
may be some tenderness in spots but it is comparatively slight and 
unimportant. There are very few morbid conditions in which this 
contrast between agonizing abdominal pain and nearly complete free- 
dom from abdominal soreness are found in the same degree. Cor- 
responding with this freedom from soreness, the abdominal walls, in 
most cases, are relaxed and devoid of tension until, at the end of thirty- 
six or forty-eight hours, all symptoms become aggravated by septic 
absorption. The increase of indican in the urine is of no avail for 
early diagnosis, as it does not become apparent before the lapse of 
twenty-four hours. In obstruction the temperature remains nearly 
normal until the conditions become septic, when it will rise rapidly 
and continuously until death. It is on the combination of symptcwns 
and on the order of the sequence that the physician must base his 
diagnosis. There is not a S3rmptom of obstruction which may not be 
present in other maladies but there are few diseases in which they will 
occur in the same order and in the same connection. 



le ORIGINAL ARTICLES. 

If we pass in review the other troubles which may perplex the prac- 
titioner in his diagnosis we may gain a clearer picture of that first stage 
in which alone operations can be done with nearly certain success. 

Obstruction may, first of all, be mistaken for indigestion with 
autointoxication. The severer forms of this kind of trouble are 
sometimes ushered in by severe abdominal pain, vomiting and collapse, 
followed by some tenderness and distension. It is rarely, however, 
that the nervous shock is as severe as in obstruction. The pain is 
more colicky in character, the bloating, when it occurs, is less localized 
and of more rapid development, and there is more fever. The one 
deciding symptom is the occurrence of diarrhea, which is the usual 
result of the condition. Should the bowels not move spontaneously, 
purgatives or enemas will almost invariably produce the desired effect. 
This is the rule, too, with all forms of enteritis. Osier, indeed, men- 
tions a case which was mistaken for obstruction but does not say any- 
thing as to the condition of the bowels. The coexistence of constipa- 
tion with severe enteritis is so rare that it may be left out of our 
calculations in forming our opinion. 

Bilious colic produced by the passage of gall-stones may cause 
great agony, feeble pulse, vomiting and temporary collapse. It is» 
however, usually of short duration and causes neither bloating nor con- 
stipation. If the trouble is prolonged, there will be tenderness in 
the region of the gall-ducts, and if the common duct is the seat of the 
disorder, there will be jaundice. It rarely causes the permanent pros- 
tration of obstruction, unless associated with severe suppurative 
cholecystitis, in which case there will be chills and high fever as well 
as great local soreness. 

The colic of lead poisoning could hardly be mistaken for intestinal 
obstruction, notwithstanding the occurrence of constipation. The his- 
tory of the patient, his occupation, his continued ill health, the blue 
line of the gums are all distinguishing features. The symptoms are 
relieved by opium and the constipation is apt to alternate with diarrhea. 
The patient has a history of multiple attacks, which gradually increase 
in severity. There is not much distension and, if any exists, it will 
disappear under opiates, in this respect differing sharply from the dis- 
tension of obstruction. 

In renal colic the patient often suffers severe shock and great pain. 
There is sometimes, but not always, nausea and vomiting. The pain 
aflfects the back, the kidneys, the ureters and the bladder. Micturition 
is often painful and the urine contains albumin and blood. There is 
tenderness along the course of the affected ureter. The bowels may 
or may not be constipated, but are rarely bloated. 

Acute pancreatitis, more than any other malady, may simulate intes- 
tinal obstruction. Beginning with an agonizing pain in the abdomen, 
with great shock and vomiting, there is a rapid distension of the 
abdomen and a tendency to collapse. The very rapidity with which 
the symptoms develop distinguishes the disorder from obstruction, in 



ACUTE OBSTRUCTION OF THE BOWEL. 17 

which the growth of the abdominal distension is much more slow. 
•The pain in pancreatitis and the tenderness are felt across the abdo- 
men in the region of the pancreas. The fever of pancreatitis begins 
much earlier than that of intestinal stoppage. As regards those inflam- 
matory affections which cause bloating and intestinal paralysis, they are 
all distinguished by high fever, leucocytosis and abd<nninal tension and 
need no further discussion in this place. In the diagnosis of invagina- 
tion, the finger may often detect the invaginated gut in the rectum in 
the shape of the end of a tube projecting into the bowel. This feeling, 
however, may be very deceptive, as I found in a case of Doctor Qiapo- 
ton's upon which I operated. The child had a severe attack of obstruc- 
tion and I felt as high up as I could reach a protrusion of this form. 
On abdominal section, however, I found no invagination but a volvulus 
high up. The pelvis was full of distended coils of intestines, whose 
pressure upon the rectal wall had forced it in and caused the deceptive 
protusion. 

In discussing the symptoms of acute obstruction we must not forget 
those forms caused by the obturation of the gut by intestinal contents. 
I was once called into the country to operate on a woman who had the 
evening before eaten an enormous quantity of pop corn, which she did 
not even take the trouble to chew. I found her suffering from agon- 
izing pain which had continued for the twenty-four hours. Her 
abdomen was enormously distended. I was preparing to operate, 
when she had a sudden evacuation of a g^eat mass of undigested pop 
com, and relief from all her symptoms. It is, of course, important to 
distinguish these cases from those in which the stoppage is due to 
strangulation or intussusception. 

I have not spoken of the later symptoms of obstruction, such a fecal 
vomiting, high fever, and failing pulse, because the diagnosis should 
never wait upon their appearance. I am confident that in nineteen 
cases out of twenty the physician could diagnosticate acute obstruction, 
if he would become thoroughly conversant with the typical symptoms. 

If a patient is seized with an agonizing pain in the abdomen, fol- 
lowed by shock, nausea, vomiting and collapse, — if then there occurs a 
localized swelling of the abdomen or pelvic cavity, if in that swelling 
no stimulus can cause vernricular motion, if during the twenty-four 
hours there is very little abdominal tenderness and no abdominal ten- 
sion, if the bowels are obstinately constipated, if the abdominal swelling 
slowly increases until the afferent coils all become distended, if with all 
of the disturbance there is little or no rise in temperature, there can be 
no doubt as to the nature of the trouble, for there is no other malady 
which will offer the same complex of symptoms in the same sequence. 

Those cases only are doubtful in which some of these symptoms are 
lacking or are modified by the existence of other morbid conditions. 
Thus the localization of the primary swelling may be rendered impos- 
sible by a fat abdomen. There may be some chronic inflammatory con- 
dition caiising abdominal tenderness, tension and swelling. There may 



18 ORIGINAL ARTICLES. 

be one or two evacuations of feces which have been lodged below the 
point of obstruction, and there may be histories of previous attacks of 
abdominal pain which may prejudice the diagnosis, but even with all 
the possibilities of mistake, a careful watch and intelligent analysis of 
the phenomena will usually lead to a correct conclusion. 

Even when the diagnosis of obstruction has been made, the occur- 
rence of a fecal evacuation and the subsidence of some of the more dis- 
tressing symptoms may lead to a mistaken belief that there has been a 
correction of the morbid condition. The patient may feel relief from 
pain, but the distension increases, the pulse beats faster and feebler and 
the temperature rises. It may be laid down as a positive rule that 
relief from obstruction is always followed quickly by a relief from 
distension. 

This is an index to which the physician should look for guidance 
when there is an apparent improvement, and never delay operative 
measures when the distensk>n is persistent. We may hope to cure 
cases of complete acute obstruction only when we meet the emergency 
by operation within the first twenty-four hours, and it behooves every 
practitioner of medicine to study carefully the means of diagnosis and 
to be prompt in his action. 



TRANSACTIONS. 



CLINICAL SOCIETY OF THE NEW YORK POLYCLINIC. 



STATED MEETING, DECEMBER 4, 1905. 
The President, JOHN J. MacPHEE, M. D., in the Chair. 
Reported by FREDERICK C. KELLER, M. D., Secretary. 

READING OF PAPERS. 
SURGICAL HERESY. 

Doctor John A. Bodine read a paper bearing the above title. He 
said in part : 

The first slipping away from the faith of our forefathers was in 
"Where and How to Amputate." No article in textual creed is 
stronger than, "Save all you can in amputations." The various and 
multiform amputations through the complex tarsus and metatarsus 
bones were the result of the necessity for speed before the advent of 
anesthesia. This golden rule was also strengthened by the argument 
that in amputations the nearer the trunk the greater the death rate, Ad 
still further bedrocked in the belief of the patient that the less of his 
anatomy lost, the less xA a cripple he was. The advent of skilled pros- 
thetic surgery has done away with peg-legs and crutches for the unfor- 
tunate victims of amputations, and today instead of traditional anatomic 
and sentimental arguments, one should be guided by a new article of 



CLINICAL SOCIETY. 1» . 

faith : "Amputate where the limbmaker can best supply the loss." Save 
all you can from tip of toe to the tarso-metatarsal joint, and discard 
every one of the many technical amputations through the tarsus in 
favor of the Syms' amputation at the ankle-joint. There is weighty 
prosthetic evidence that even this point of amputation should be dis- 
carded in favor of removal seven inches above the ground line. There 
is but one American firm of limbmakers which claims it can fit partial 
foot amputations with a satisfactory appliance, and even it admits that 
the advantage is chiefly economic, the apparatus costing less than in 
the case of higher amputations. 

After leaving the point of seven inches above the ground line, the 
rule of save every inch possible holds good until within two inches of 
the knee-joint. In amputations of the thigh above this point, one 
should save every inch possible. 

In the event of future improvements in artificial substitutes, nulli- 
fying the potency of the speaker's. argument, he submitted that in par- 
tial foot amputations the technical and ccxnplicated textual amputations 
should be ^discarded and the foot treated as one bone, the rule then 
being, "Save all you can, from toe to hip-joint." 

There is a tendency today Jo attach too much importance to the 
laboratory verdict in diagnosis of surgical lesions. Important as this 
evidence is, it is not always pathognomonic, and in few surgical diseases, 
alone and unaided, can it be relied upon to formulate a diagnosis. It 
furnished evidence, valuable evidence, but unless clihical history and 
clinical symptoms support this testimony the laboratory evidence should 
be discarded. In the surgical lesions of the stomach, can cancer, 
pyloric obstruction or ulcer be diagnosticated alone by the test-tube or 
microscope? Can chemical or microscopic examination of the feces 
locate or even diagnosticate surgical lesions of the intestinal tract? 
Which should one refuse elective operation, a patient who passed a 
low quantity of urine, with low specific gravity, or one with full quan- 
tity of normal specific gravity, with all the pathologic casts and epithe- 
lium discoverable with the microscope ? 

DISCUSSION. 

Doctor Ferdinand M. Jeffries: So far as Doctor Bodine's 
remarks concern the laboratory, I must agree with him in the main, 
but some of his assertions I cannot coincide with. With regard to 
cancer, I feel that if the pathologist's report is that of cancer, no 
matter what the clinical findings may be the surgeon should proceed 
on the assumption that it is malignant in character. Regarding appen- 
dicitis, it is generally known that hematology is not the useful diag- 
nostic aid that at one time it was hoped it would be, nevertheless, 
instances are on record in which it has been of great service. There- 
fore, the patient should be given the benefit of this examination on all 
occasions. The surgeon should give the benefit of all clinical aids ; the 
laboratory is one of them. 



20 ORIGINAL ARTICLES. 

REPORTS OF CASES. 
ATRESIA OF THE BOWEL, 

Doctor Joseph E. Fuld: I wish to show this specimen. The 
child was bom normally, at full term, and on the morning of the third 
day vomited material which looked like meconium. It had not defe- 
cated since birth, and refused the breast. ^Physical examination showed 
a well-formed, healthy baby, with no outward deformities. The abdo- 
men presented marked lateral and median distension, but no signs of 
hernia. Examination with a large sized Kelly cystoscope showed a 
distinct narrowing of the lumen of the bowel between one and one- 
half and one and three-quarters inches from the anus. In the centre of 
the narrowest part a small dimple was distinctly visible, and through 
this a uterine sound was introduced with some difficulty for about one 
and one-quarter inches. No mass could be felt in the pelvis. A diag- 
nosis of atresia recti was made, and iliostomy was performed under 
chloroform anesthesia. A median incision two inches long was made 
below the umbilicus, and in trying to get into the peritoneal cavity the 
much-distended bladder, which resembled the parietal peritoneum, was 
nicked and considerable urine escaped. An artificial anus was made 
in the lowest part of the ileum, which was packed off and surrounded 
with gauze. The patient left the table in a fair condition, but was not 
rielieved by the operation, and died thirteen hours later. Postmortem 
examination showed the small intestine to be full of meconium and 
considerably distended. The pylorus was distinctly thickened for a 
distance of about three-quarters of an inch, making a firm ring, and 
producing a slight stenosis. Section through the thickened tissue 
showed very marked increase of the muscular layer. At the normal 
end of the ileum, instead of the normal valve there was complete 
closure. Beyond this the large bowel was patent throughout, com- 
municating below with the rectum. In the centre of the septum was a 
dimple, corresponding to the ileocecal valve. The large bowel wa:> 
the size of an adult ureter, and the cecum was about three-quarters of 
an inch in length and about twice the size of the sigmoid colon. 

SPONTANEOUS RUPTURE OF THE UTERUS DURING PREGNANCY, 

Doctor Louis J. Ladinski : I desire to show a uterus and adnexa 
which I removed from a patient about a week ago. The history given 
was that pregnancy followed four years after operation at the Polyclinic 
Hospital, and just prior to impregnation there was chronic endome- 
tritis with mattery discharge. Examination through the vagina during 
the fourth month of pregnancy showed the uterus to be adherent, but 
there was no deformity in size, form or position. Three days before 
operation a small blood spot was noticed, and I adyised absolute rest 
in bed and morphin. There was no further showing of blood, but the 
following day the patient complained of pain in her back, and two days 
later she collapsed. Her pulse was rapid and almost imperceptible at 
times, and she had intense pallor and rapid respiration. Her abdomen 



CLINICAL SOCIETY. 21; 

was distended, not in the shape of a dome, but over its entire surface. 
A diagnosis of ruptured abdominal pregnancy was made, and immedi- 
ate operation advised. When the patient was placed on the operating 
table the fetus was found in its sac, floating about in the abdomen. 
There was a large rent in the uterus. The patient made a good 
recovery. Uterine rupture during pregnancy is rare, and must not be 
confounded with rupture during labor. The most frequent cause for 
the former is the giving way of the scar of a previous Cesarean section, 
or of the connective tissue formed after a deep curettage. In the case 
described, one portion of the posterior wall of the uterus was as thin as 
paper. If a history of the operation performed four years before could 
be obtained it would assist in determining the cause of this condition. 

DISCUSSION. 

Doctor Benjamin Torrens : Possibly the patient was the same as 
one on whom I operated about four years ago at the Polyclinic Hos- 
pital. On inserting the curet into the uterine cavity, it was found that 
the instrument entered the abdominal cavity through an opening in the 
anterior uterine wall. It was immediatly withdrawn, and digital 
examination disclosed two perforations of the wall, with about one inch 
of connective tissue separating them. Each of the openings was large 
enough to admit the passage of two fingers. The uterus was packed 
with iodoform gauze, the culdesac of Douglas was opened, and the 
small intestine was found adherent to the anterior uterine wall at the 
site of perforation. This was detached and the pelvis packed with 
gauze. The patient made an uneventful recovery. 

Doctor Robert H. M. Dawbarn: This case reminds me of an 
instance in which I made a diagnosis of abdominal rupture of preg- 
nancy, even going so far as to determine the position of the fetus. 
There was some bleeding from the uterus, which was enlarged and 
quite soft. The abdomen, when opened, allowed the escape of a very 
great amount of bloody material, and this being removed, it was seen 
that all of the viscera, the bowels especially, were covered with a new 
growth which proved to be sarcoma, the largest clump of which had 
been mistaken for the fetus. 

DERMOID CYST. 

Doctor Dawbarn : I also wish to show a dermoid cyst which I 
removed a week ago from a girl nine years of age. The dermoid is 
much larger than the average specimen of its kind. There is a Kstory 
of half a dozen paroxysms of pain, and when the specimen was removed 
the pedicle was found to be twisted upon itself a great many times. 
Apparently this occurred coincidentally with the pain, and of course 
occasioned hemorrhage of the sac. The solid portion of the cyst is 
about the size of a small tgg and is filled with teeth and bones. 

TENDON TRANSPLANTATION IN THE FOREARM, 

Doctor John A. Bodine : I wish to present this patient. He is a 
butcher by trade, and was on the top of a high stepladder when he 
slipped and caught at a large meat hook on the side of the wall. The 



22 ORIGINAL ARTICLES. 

hook penetrated the forearm at the base of the thum, picking up the 
three tendons on the radial side — the two tendons forming the anatom- 
ical snuff-box and that of the supinator longus. He swung from this 
hook with his entire weight of one hundred seventy pounds. The 
tendons did not break, but pulled loose from their attachments to the 
muscles in the forearm, one of them hanging down for twelve inches. 
He wrapped his butcher apron around the forearm and tendons and in 
a few hours was on the operating table. The tendons were identified 
and two of them passed through the canal in the anterior ligament of 
the wrist and sutured in their proper positions. The loose tendon of 
the supinator longus, however, was so long that opening of the muscu- 
lar planes of the forearm, near the elbow, would have been necessary in 
order to stitch it in place. It was therefore thought best to transplant 
it into the tendons of the extensor primi internodii pollicis. The wound 
healed kindly and the patient can now do with this thumb all that he 
can do with the other one. 

VARICOSE VEINS OF THE LOWER L2MB, 

Doctor Bodine: I also wish to present this patient. Of middle 
life, she presented for operation the worst type of this condition. Great 
masses of infected thrombi were present on the inner side of the leg. 
Three weeks' rest in bed, with ice-bags, et cetera, was insisted upon, 
until all inflammation and sepsis had disappeared. She was then oper- 
ated upon. It is my belief that when the Trendelenberg operation can- 
not be utilized the only other to be recommended is that of excision of 
the entire internal saphenous vein, because if the blood current in the 
vein is cut off by any other operation, the walls of the useless vein may 
become a foreign body and require removal. The operation recom- 
mended by me is that of Caseta, in which the entire vein is removed 
through three or four small cuts in the overlying skin, the vein being 
pulled out subcutaneously, the numerous tributary vessels being torn 
across, but not litigated. At the junction of the middle with the lower 
third of the leg, the skin and subcutaneous fascia are then cut through 
to the muscles, the cut encircling the entire limb. After this operation 
the patient is usually in the hospital for two weeks. In every one of 
the twenty cases in which the speaker had operated according to this 
method the cure had been perfect. 

ACUTE INFECTIOUS CHOLECYSTITIS. 
Doctor Bodine: Here is a girl, seven years of age, who entered 
the hospital fot^r weeks ago. The question of diagnosis is interesting 
in -this case, because, judging from the symptoms, the condition might 
have been intestinal obstruction, pneumonia, diaphragmatic abscess, 
appendicitis, or acute infectious cholecystitis. As is well known, at 
times it is very difficult to differentiate in these acute abdominal lesions. 
Her vomiting was not progressive and her fever was too high for 
intestinal obstruction. The principal point of tenderness was too high 
> for appendicitis, unless it were of the type in which the pain is reflected 
to the liver. Her entire right abdomen was rigid, and respiration. 



HEART DISEASE OF NEPHRITIS 28 

while rapid, was not the dominant feature of the situation, although a 
cough was present from bronchitis. Diagnosis of acute infection of 
the gall-bladder was therefore tentatively made, and proved correct on 
operation. The liver was two and one-half inches below the costal 
border, and projecting below the liver was the tense, swollen gall- 
bladder. This was quickly stitched to the abdominal wall, drained, 
but not removed. The child's condition was so critical that speed was 
an essential feature of the case. Four months previous to this illness 
she had an unusually severe attack of measles, followed by a persistent 
bronchitis and cough. From .that time to the present illness she has 
complained frequently of pain in the pit of her stomach, so it seems 
quite probable that the measles were the cause of the infected gall-blad- 
der by metastasis. 

ORIGINAL ABSTRACTS. 



MEDICINE. 

By GEORGE DOCK, A.M., M. D., D.Sc, Ann Arbor, Michigan. 

PltOFUSOR OF MBDICINS IN TMB UMIVBRSITY OP BflCMIGAlt. 

AND 

DAVID MURRAY COWIE, M. D., Ann Arbor, Michigan. 

FIRST ASSISTANT IN BfBDIClNB IN THB UNIVBBSITV OF BflCMIGAN. 



THE CAUSE AND IMPORTANCE OF THE HEART DIS- 
EASE OF NEPHRITIS. 

Passler (Sammlung Klin. Vortrdge, Inn. Med. Number CXXIII) 
has made a study of this subject, so often discussed in the past, and has 
brought to it the most advanced knowledge of cardiac physiology and 
pathology, since he has been an active coworker with Krehl, Romberg 
and others of the Leipzig school. Only the most important conclusions 
can be given here. 

( 1 ) The cardiac hypertrophy in nephritis is the result of the kidney 
disease. 

(2) There is probably at first an increased irritability of the vaso- 
'constrictor apparatus in consequence of the renal lesion, subsequently 

arterial spasm and increased resistance of the greater circulation. In 
cases where there is extensive arteriosclerosis, especially in the thoracic 
aorta or the small arteries of numerous organs in the splanchnic area, 
part of the hypertrophy of the left ventricle must be attributed to this 
complication. 

(3) The hypertrophy of the left auricle and the right heart in 
nephritis is a result of insufficiency of the left ventricle. 

(4) The polyuria of many renal diseases, especially of contracted 
kidney, does not depend upon an increased "filter pressure" of the 
glomerular capillaries ; it is much more probable that the blood pressure 



24 ORIGINAL ABSTRACTS. 

in the renal capillaries is not elevated above normal even in cases of the 
highest arterial pressure, as the excess must be used in overcoming the 
resistance in the small arteries. 

(S) Therapeutic measures for preservation of compensation, and 
in disturbed compensation of the heart in interstitial nephritis, must 
regard not only the increase of cardiac power, but more especially the 
lowering of arterial r^istance. (For the latter purpose the author 
recommends nitr(^lyccrin). G. d. 



SURGERY. 

By frank BANGHART WALKER, Ph. B., M, D., Detroit. Michigan. 

rROVBSSOK or SUKGBKT AMD OPBRATiyB SUKGBKT IN THB DBTKOIT POSTGKADUATB SCHOOL OV MBDICIM 
ADJUMCT PKOFBStOR OF OPBKATIVB SUBGBKT IN THB DBTBOIT COLLACB OF MBDICINB. 

AND 

CYRENUS GARRITT DARLING, M. D., Ann Arbor. Michigan. 

CLINICAL ntOFBSSOB OF SUBGBKT IN THB VNIVBBSITT OF MICHIGAN. 



TUBERCULOSIS OF THE CERVICAL LYMPH NODES. 

Daniel Eisendrath, M. D., of Chicago, in Surgery, Gynecology 
and Obstetrics, Volume II, Number I. 

This old, familiar subject has made some advances of late, so that 
the cause, diagnosis and treatment at the present time will be consid- 
ered. It has long been known that the tonsils are the common portals 
of entry of infection in the cervical lymph nodes. This has been con- 
firmed beyond doubt by examination of the tonsils and adenoids 
removed from children. When the children crawl on the floor their 
tonsils probably become infected by the dust which lodges in them. 

Infection may also come from the temporal bone or through 
carious teeth, by tubucular lesions of the buccal and mucous membranes. 
These latter represent a very small proportion of the cases. The tuber- 
cular organisms may remain latent in the cervical lymph nodes for many 
years, and then suddenly become active. Every case should be care- 
fully examined before operation to see if it is complicated by disease 
of the tonsils, or by the presence of adenoids. The diagnosis of the 
chronic forms, such as have extended over .a period of months or years, 
will be easy, and other cases, also, where the disease runs a very acute 
course so that caseation may occur, within two or three weeks after the 
onset of the disease. 

Another class should be considered which Fischer has termed a 
pseudoleukemic form of tubercular lymph nodes, where the axillary 
and inguinal node are enlarged as well as the cervical. There is a grad- 
ual enlargement; with no tendency to softening, or the formation of 
adhesions between adjacent nodes. 

Without a reliable history it is impossible to make a diagnosis. 
Besides these may be mentioned syphilitic lymphatic leukemia, chronic 
nontubercular hyperplastic nodes, lymposarcoma, and secondary car- 



CANCER OF THE UTERUS. 25 

cinomata. The treatment is divided into prophylactic, nonoperativc, 
and operative. Prophylaxis is the same as may be applied in all 
instances for avoiding tuberculosis. To this may be added the removal 
of diseased tonsils and adenoids whenever found. 

When, for any reason, an operation is deemed inadvisable or objected 
to, the patient should be sent to the mountains or seashore. When this 
is impossible tonics of cod-liver oil, guaiacol, or iodide of iron will be 
beneficial. If the condition is active medical treatment is of little avail. 

The operative treatment consists in removing every tuberculous 
node, and, at the same time, the tonsil and diseased adenoids. The 
incision is made over the middle of the sterno-cleido-mastoid from one 
end to the other if necessary, and all the sinuses if they exist, are dis- 
sected out. The muscle is pulled backwards and the nodes exposed. 
Care is taken to catch every bleeding point at once. Few of the vessels 
require ligature except the external jugular vein, which is nearly always 
severed. The dissection is made with blunt-pointed, short-bladed, 
curved scissors. The writer states that in this way he has exposed the 
internal jugular vein from the chin to the clavicle without injury. By 
this method nodes can easily be stripped from the wall of the vein with- 
out injury. Occasionally a short vessel Avill be found extending directly 
from the internal jugular vein to the overlying node which will give 
troublesome bleeding if it is cut. This may be seized with a stitch and 
a parietal ligature applied. Care must be taken not to injure the spinal 
accessory nerve which emerges from the sterno-mastoid about the 
middle, and passes almost transversely across the triangle to enter the 
trapezius. A number of enlarged nodes are sometimes encountered at 
this point. The thoracic duct must not be forgotten when operating 
on the left side. A thorough removal of all fat will greatly aid in 
securing a perfect cure. c. g. d. 



GYNECOLOGY, 

By REUBEN PETERSON, A. B., M. D., Ann Arbor, Michigan. 
ntoratsox or gthbcologt and obstbtxics in tmb ukivbesitt op Michigan. 

AND 
CHRISTOPHER GREGG PARNALL, A. B., M. D.. Ann Arbor. Michigan. 

FIRST ASSISTANT IN GTNBCOX.OGT AND OMTBTUCS IN TMB UNIVBXSITY OV MICHIGAN. 



HAS EXPERIENCE SUSTAINED THE MORE RADICAL 
OPERATION FOR CANCER OF THE UTERUS? 

Clark (Surgery, Gynecology, and Obstetrics, Volume II, Number 
II) reviews his experience in the operative treatment of cancer of the 
uterus. Qark, Rumpf, and Ries, were among the first to advocate the 
extensive operation of removal of the iliac glands along with the uterus 
and appendages. The results of this method have, however, been dis- 
appointing. The immediate mortality is very great and recurrence is 
just about as frequent as in other less radical procedures. There is a 



26 ORIGINAL ABSTRACTS. 

great difference of opinion between various operators regarding the 
time of metastasis in cancer of the cervix. The writer evidently now 
adopts the view advanced by Cullen and Winter that metastasis occurs 
comparatively late in the disease. When the operable glands are 
involved according to the studies of Schauta, only thirteen per cent show 
no involvement of the upper or nonoperable glands. Consequently, 
when there is extension of the cancerous process to the glands, the 
outlook is not at all hopeful even with a so-called radical operation. 

In view of these findings, the author now limits his operative inter- 
ference to a thorough local extirpation of the uterus and adnexa, includ- 
ing the upper portion of the vagina and the greater part of the broad 
ligaments and parametrium. The abdominal route is preferred to the 
vaginal, on account of the better opportunity to get well out on the 
broad ligaments. c. g. p. 



OBSTETRICS. 

By WILLIAM HORACE MORLEV, Ph. B., M. D., Ann Arbor, Michigan. 

DBMOMSTRATOR OF OBSTBTRICS AKD GTNSCOLOCT IM TMB UMITBIUITr OV MICHIOAN. 

AND 

WALES MELVIN SIGNOR. M. D., Ann Arbor, Michigan. 

ASStSTAMT IN OSSTBTRICS AND GTNBCOLOGY IN THB UNITBRSITT OF MICHIGAN. 



CAESAREAN SECTION. 



Olshausen {Zentralblatt fiir Gyndkologie, 1906, Number I) 
reports his results in one hundred eighteen cases. This report is sup- 
plemental to one made by him in 1902 {Deutsche Klinik, Band IX), an 
abstract of which appeared in iljt $^0utan anb Surgton for February, 
1904, page 81. In his one hundred eighteen cases Olshausen sum- 
marizes the indications as follows: 



Contracted pelves, 


91 cases 

7 " 
6 " 

4 ** 
4 " 
2 *' 
2 ** 
2 " 


UrCiampsia, 

Myomata, 

Carcinoma uteri. 

Fixation of vagina, 

Nephritis, 

Vitium cordis. 

Stenosis of vagina and cervix, 



Among the cases of contracted pelves w^ere those of the rachitic type 
most often seen. Seventy-one of the ninety-one cases were due to 
rachitis. The remaining twenty cases were distributed as follows: 
Five generally contracted, five obliquely contracted, two transversely 
contracted, two pseudoosteomalacic, three skoliotic, one kyphoskoliotic 
and two contracted or narrowed from exostoses. In eclampsia the 
author prefers Caesarean section to forceps or to version and extraction. 
He further states that the use of morphia in eclamptic cases is danger- 
ous to the fetus. 



TREATMENT OF DIPHTHERIA. 27 

His technique has not been radically changed since his last report. 
He does not put as much faith in the course of the round ligaments in 
the determination of the placental site, as he did formerly. It' can 
usually be located from the injection of the uterine wall and from the 
outpouching of either the anterior or posterior wall. Hemorrhage is 
not to be feared as it is easily controlled after the cut edges of the 
uterine wall have been brought together. In seven patients this oper- 
ation was performed twice. In two three times and in three four times. 
All these cases recovered. In his ninety-one cases of contracted pelves 
Olshausen has only lost nine cases. w. h. m. 



PEDIATRICS. 

By ARTHUR DAVID HOLMES, M. D.,C. M., Detroit, Michigan. 



THE UNCERTAINTIES OF EARLY DIAGNOSIS AND THE 
NECESSITY OF EARLY AND VIGOROUS TREAT- 
MENT OF DIPHTHERIA. 

McMahon (Pediatrics, Number IV, 1905) says the death-rate in 
Ontario as elsewhere is too high, and attaches much blame to faulty 
or tardy diagnosis and late and half-hearted treatment. He gives as 
causes of failure : 

( 1 ) The physician's attention is not especially directed to the throat 
and he fails to look at it and diagnoses something else ; by the time he 
recognizes his error, the case is hopeless. The golden rule is "always 
examine the throat of a sick child, no matter what its symptoms are." 

(2) He examines the throat and thinks he has a case of tonsillitis 
or coryza or croup to deal with, or that even if it is diphtheria it is so 
mild that the old-fashioned remedies are sufficient for its cure. 

(3) He fails to follow up a suspicious case and finds, when too 
late, that the patient is in a desperate condition. 

(4) He treats one amongst many children and fails to protect the 
others exposed to contagion, by a preventive injection. 

(5) He uses antitoxin, but is half-hearted and does not use enough. 

(6) In cases of laryngeal diphtheria he uses antitoxin — perhaps in 
large doses — ^but fails to make an early resort to accessory remedies, 
such as calomel fumigation and intubation. 

(7) He makes an early diagnosis, but puts off the injection of anti- 
toxin until tomorrow or the day after. 

The author says the diagnosis of diphtheria should be made at the 
first visit if possible. He does not believe we should depend or wait 
for a bacteriological examination. In every case in which there is even 
a suspicion of diphtheria, give antitoxin at once and give it freely. If 
bacteriological examination shows the presence of the diphtheria 
bacillus, give an injection to each of the children of the household to 
prevent the spread of infection. In laryngeal diphtheria the author 



28 ORIGINAL ABSTRACTS. 

treats his cases as follows : (i) Inject antitoxin (full doses) and fume 
calomel under a tent (thirty grams an hour) until stenosis is relieved. 
(3) Intubate early if symptoms demand. To have a low death-rate 
one must be prompt, bold and fearless in his treatment. In specially 
malignant cases he recommends twenty thousand to thirty thousand 
units as an initial dose injected into the median basilic vein. 



ORTHOPEDICS. 

By IRA DEAN'LOREE, M.D., Ann Arbor, Michigan. 

FIRST ASSISTAMT IN ftVSGBRY IN THB UNIVBRSITY OV MICHIGAN. 



A CASE OF EXCISION OF THE HEAD OF THE HUMERUS 
FOR CONGENITAL SUBACROMIAL DISLOCA- 
TION OF THE HUMERUS. 

John B. Roberts, M. D., of Philadelphia (American Journal of 
the Medical Sciences, December, 1905). His patient was a boy age 
three years who came to operation December 5, 1903. The condition 
present was as follows: The head of the left humerus could be felt 
under the acromial process. The humerus was firmly abducted with 
the external condyle pointing forward. The elevation of the arm, 
so far as voluntary movement was concerned, was impossible and 
other movements restricted. He therefore decided to replace the head 
by operation, resecting the head for false joint providing the former 
method failed. 

A vertical incision was made over the prominence of the head 
below the acromion and the capsule opened. As the attempt failed, a 
second incision on the front of the shoulder was made and carried 
down to the deep layer of muscles. Combined efforts from the two 
points gave no results. 

He concluded that only a bloody and prolonged dissection would 
expose the glenoid fossa; even if reduction resulted he might obtain 
only a stiff joint, which was no better than the original deformity; 
that excision of the head would give as good, if not a better joint, with 
less risk. 

The bone was sawed close to the head but in its removal the long 
head of the biceps was severed. Both cuts were closed without drain- 
age and the forearm supported by a sling. 

Examination June i, 1905. The left arm was three-quarters inch 
shorter than the right arm. Grating at the false joint with passive 
motion. Rotation not so complete as on right side. Elevation of the 
humerus restricted and scapula moves with it, if passive movement 
is extensive. Humerus still rotates slightly forward. The patient 
can touch the back of his ear and neck on the left side, put his hand 
to his mouth, and can clasp his hands behind his back in the lumbar 
region. The belly of the biceps stands out prominently in the middle 
of the arm due, no doubt, to the division of its long head. He cannot 



SUBSTITUTES FOR NITRATE OF SILVER. 29 

lift the left hand over his head but could merely touch the occipital 
region. He could put the left hand on the opposite shoulder and bring 
the elbow nearly in contact with the ribs. 

Doctor Roberts thinks a large proportion of these cases result from 
intrauterine causes as many times they occur on both sides in the same 
patient and in more than one child of the same family. 



OPHTHALMOLOGY. 

By WALTER ROBERT PARKER. B. S.. M. D., Detroit. Michigan. 

PROFBSSOR OF OPHTBAUfOLOGT IN TMB UNIVBIISITY OF MICHIGAN. 



PROTARGOL AND ARGYROL AS SUBSTITUTES FOR 
NITRATE OF SIVER. 

Doctor G. E. de Schweinitz (Ophthalmic Record, January, 1906) 
expresses his views concerning the use of the newer salts of silver. 

At one time this writer had employed protargol very freely as a 
substitute for nitrate of silver but had found it comparatively unsatis- 
factory and had abandoned its use. He had employed argyrol first as 
a substitute for nitrate of silver in all forms of conjunctivitis, except 
diplobacillus conjunctivitis, in the treatment of purulent conditions of 
the lachrymonasal passages, in the management of infected cervical 
ulcerations, and in the preparation of the conjunctival sac prior to 
operations. In his earlier experiences he had been inclined to think 
argyrol was a satisfactory substitute for nitrate of silver in various 
conjunctival inflammations, and particularly in ophthalmia neonatorum, 
but within the last year he had met with so many cases wherein it had 
been necessary to abandon this agent and substitute nitrate of silver, 
that his faith in the remedy had been seriously shaken. 

The doctor was satisfied that nitrate of silver properly applied in 
gonorrheal conjunctivitis of newborn babies and in gonorrheal conjunc- 
tivitis of adults frequently was a more satisfactory remedy, although 
he recognized its many disadvantages. He had been accustomed to 
employ argyrol by the so-called immersion method, and continued so to 
use it in certain cases, but not to the exclusion of nitrate of silver. He 
thought the plan advocated by Bruns, that after its use for a few days 
nitrate of silver should be applied once a day by the surgeon, and in 
the meantime the conjunctiva should be kept flushed with argyrol, a 
good one. In many cases of gonorrheal conjunctivitis he did not 
believe that of itself it was as safe a remedy as nitrate of silver, and in 
a certain number of cases it failed completely and nitrate of silver had 
to be substituted. He continued to find argyrol useful as an adjunct 
in many forms of conjunctivitis, particularly of mild type, and thought 
it a satisfactory remedy for irrigating the lachrymonasal passages if 
purulent discharge was present. He also continued to use it in cleaning 
the conjunctiva, if there was hyperemia or slight discharge, preparatory 
to operations on the globe. Taking his experience as a whole, he was 



30 ORIGINAL ABSTRACTS. 

satisfied that neither protargol nor argyrol represents in any sense a 
satisfactory substitute for nitrate of silver in gonorrheal affections of 

the conjunctiva. 

* * * . 

Note. — To use nitrate of silver to its best advantage requires per- 
haps more skill and careful observation than the use of any single drug 
in the armamentarium of the opththalmic surgeon; while nothing is 
more simple than the directions for use of its substitutes. When prop- 
erly used, nitrate of silver still holds its supremacy. Our experience in 
the University clinic is in exact accord with that of Doctor de Schwei- 
nitz. 



OTOLOGY. 

By R. bishop CANFIELD. A. B.. M. D., Ann Arbor, Michigan. 

PKOVBSSOR OF OTOLAKYNCOLOGY IN THE UNIVBRSITY OF MICHIGAN. 
AND 

WILLIAM ROBINSON LYMAN. A. B., M. D., Ann Arbor. Michigan. 

DBMONSTKATOR OF OTOLARYNGOLOGY IN TKB UNIVBRSITY OF MICIIIGAN. 



A REPORT OF TWO CASES OF MASTOIDECTOMY SINUS 

THROMBOSIS. 

McKernon (Archives of Otology, Volume XXXIV, Number IV). 
The first case was a male twenty-six months old, always healthy save 
for an attack of acute otitis one year before. When first examined 
there was a mucopurulent discharge in the external auditory canal, 
examination of which showed staphylococcus infection. The tympanic 
membrane was bulging and there was a small perforation in the 
posterior quadrant. The temperature was 102° and the child was 
rather drowsy. The t)mipanic membrane was incised and in twelve 
hours the temperature was 100''. On the fifth day temperature rose to 
103.2° and there were signs of mastoid involvement. The mastoid 
was opened and a small amount of pus found in the antrum. For 
several days the patient did well and the wound looked healthy except 
in a small spot over the sigmoid groove in the region of the knee. 
The temperature was 103°, the child restless and refusing nourishment. 
The temperature the following day was 104.8° and the wound was 
bathed in pus. A diagnosis of sinus involvement was made, the sinus 
was opened and a clot removed, free hemorrhage obtained and the 
child apeared stronger. For four days the temperature ranged between 
103° and 100°. On the fifth day the temperature went to 104.2°. The 
child was very restless and looked septic. A few hours later the hands 
and feet became cold, the temperature reached 105° ; pulse 160. The vein 
was ligated below the clavicle and resected to its exit from the skull. 
It was found to contain a clot for nearly an inch below the skull. The 
facial vein was also involved and nearly an inch was resected. The 
wound closed and patient made an uninterrupted recovery. 



DRAINAGE OF THE FAUCIAL TONSILS. 31 

The second case was a female, age thirty, who ckveloped an acute 
otitis twenty-four hours after a partial turbinectomy with symptoms 
of a profound systemic infection. The tympanic membrane which was 
bulging was incised. The discharge showed many streptococci and a 
few pneumococci. The temperature was 102.2° and the mastoid tender. 
The temperature remained about the same and on the third day the 
mastoid was opened and found to be involved throughout. Within a 
few hours there was a sudden rise of temperature to 103.8° and a 
sudden fall to 98.4°. For six days the patient did well save for a slight 
fluctuation of temperature. On the tenth day there was a sudden rise 
to 103.8° with intense headache and marked variations of temperature 
during the next twenty-four hours. Sinus involvement was diagnosed 
but owing to the extreme weakness ol the patient operation was delayed 
and stimulating treatment given for five days. On the sixth day the 
sinus was opened, and a large clot found extending backwards from 
the knee about two inches. In the lower part of the vein there was 
disintegrated clot and pus. There the internal jugular was exposed, 
ligated and resected. At the same time many suppurating glands were 
renK)ved, the wound was sutured and the patient made a good recovery. 
All specimens removed contained numerous streptococci. It is worthy 
of note that in this case there were no chills, nausea, or vomiting. 

From the subsequent history of the first case it is seen that it would 
have been wiser to have resected the vein at the time the sinus was 
opened, as there may be free hemorrhage at the bulb while the vein in 
the neck still contains a thrombus. Doctor McKernon feels like ligating 
the vein in all cases at the time of operation when the condition of the 
patient will allow. r. b. c. 

LARYNGOLOGY. 

By WILLIS SIDNEY ANDERSON, M. D., Detroit. Michigan. 
AmsTAirr to tub cmair ow lastnooloot in thb dbtkoit collboi ow mbdicini 



THE LYMPHATIC DRAINAGE OF THE FAUCIAL 
TONSILS. 

George Bacon Wood (American Journal of the Medical Sciences, 
August, 1905) has made a number of dissections of injected specimens 
to show the Ijmiphatic drainage of the faucial tonsils. The fate of 
microorganisms which have entered the parenchyma of the tonsils is 
dependent upon two factors : First, the pathogenic potency of the germ 
itself, and second, the vital resistance offered by the tissues to its 
invasion. It has been proven that foreign bodies in the crypts can pass 
through the epithelium into the interfoUicular tissue. The absorption 
is probably due to the action of the muscles and the presence of the 
lymph current. 

' The author describes the different lymphatic chain of glands and 
gives the regions they drain. The direction of the drainage from the 



32 ORIGINAL ABSTRACTS. 

tonsils as established by the study of the injected specimens is as 
follows : 

"The lymph vessels pass from the external portion of the tonsil 
through the peritonsillar connective tissue, the pharyngeal aponeurosis, 
and the superior constrictor of the pharynx, and one, two or more 
fine vessels run obliquely in a downward, posterior, and outward course, 
passing below the facial artery. Bending more posteriorly the lymph 
vessels next run between the internal jugular vein and the stylohyoid 
muscle, reaching finally the superior surface of an enlarged lymph 
gland, placed just beneath the anterior border of the sterno-cleido~mas- 
toid muscle, where it is crossed by the posterior belly of the digastric 
muscle. The efferent vessels from this gland are generally two or three 
in number, and pass into the neighboring glands of the internal jugular 
group. Further anastomoses which connect the lower glands of the 
internal jugular group with those receiving the tonsillar drainage form 
a complete lymph channel, through which tonsillar lymph finally empties 
into the jugular lymph trunk." 

The author gives the name "tonsillar lymph gland" to the gland 
placed external and slightly anterior to the internal jugular vein, and is 
embedded in loose areolar tissue containing more or less fat. This 
gland is especialy involved in infections from the tonsil. 



DERMATOLOGY. 

By WILLIAM FLEMING BREAKEY. M. D., Ann Arbor. Michigan. 

CLINICAL PROFBSSOR OP DIRMATOLOGT AMD STPHILOLOGT IN THB UNIVBKtITY OP MICHIGAN. 



ON THE INFLUENCE OF LIGHT IN THE PRODUCTION OF 
CANCER OF THE SKIN. 

Doctor James Nevins Hyde, of Chicago, Professor of Diseases of 
the Skin in Rush Medical College, read a paper on this subject before 
the Ann Arbor Medical Qub, November 8, 1905. The entire article is 
published in the American Journal of the Medical Sciences for January, 
1906, but the following abstract presents the salient points thereof. 

The paper was a comprehensive discussion of the pathology, etiol- 
ogy, prevalence, and mortality resulting from conditions beginning as 
cancer of the skin, particularly with reference to the damaging effects 
of solar light and :r-rays under certain conditions, and radiotherapy in 
general ; also to the lesser prevalence and death rate from cancer in the 
colored races and inhabitants of warmer countries, attributed to the 
protection against ill effects of excessive light, afforded by the greater 
pigmentation of the skin. 

It is impossible to give, in the limits available, an adequate abstract 
of the scope and value of the paper, illustrated with several paintings 
and maps, supported by statistics, and presented in the interesting and 



CANCER OF THE SKIN. 33 

forcible style of the distinguished author. It should be read in full to 
be appreciated. 

Discussing the various forms of epitheliomata, "these all represent 
variations of a single morbid process ... an invasion of neigh- 
boring tissues through the avenue of the lymphatic spaces by epithelial 
cells." Considering the causes of this change, which may reach a point 
when destruction of life results, and noting the recent research work 
on the subject conducted by scientific men in laboratories equipped and 
maintained by generous private and public benefactions, "as yet, how- 
ever, agreement has not been reached respecting the essential factors 
in the genesis of this scourge of the human family." 

"The chief causes of cancer heretofore assigned by writers on the 
subject may be classed as follows : First, proliferation of the epidermis 
proceeding from stray bits of the germinal layer separated in the embryo 
from their proper attachments and included in the growing tissues 
(Cohnheim) ; second, loss of equilibrium — ^pressure and counterpres- 
sure — ^between the epidermis and the corium; third, disturbance of 
equilibrium between waste and repair; fourth, congenital tendency to 
reversion of epidermal cells to a simpler and undifferentiated type ; fifth, 
parasitism." There are many and seductive reasons for searching for 

a parasite as the cause of cancer It is difficult to conceive 

that the human body in so large a proportion of cases, without intro- 
duction of a foreign element, can evolve a growth of such malignant 

potency A decided reaction, however, seems to have set 

in against the tide which bore in the direction of parasitism of cancer. 

. . Many of the bodies which it was once believed would prove to 
be parasites are now known to be irregular cell inclusions. . . . 
Various considerations, which need not be cited in full, have for the 
time lessened the belief of scientific men in the hypothesis of parasitism 
in cancer. 

"Carcinoma of the sailor's skin," also described by Unna, in which 
cases the ears, the cheeks, the temples, the backs of the hands, and of 
the fingers first become mottled and pigmented, nonpigmented islands 
of skin later developing between the freckles, with thickening, roughen- 
ing, and comification of the horny layer follow, and eventually, as in 
xeroderma pigmentosum, the sebaceous glands become hypertrophied 
and indolent cancerous growths of the "rodent ulcer" type form. There 
is both hyperkeratosis and acanthosis, and conical homy taps push 
downward into the corium; the lymph spaces of the lattei^ become 
largely dilated ; the mast cells multiply, fissures form, and finally papil- 
lary cancerous growths furnish flabby ulcers which refuse to heal. 

These instances of malignant cancer occurring obviously as a result 
of exposure to light justify the inquiry whether all cutaneous cancers 
are not influenced in their origin and career by the actinic rays. It 
would be venturesome without strong proof to make a broadly affirma- 
tive answer to such a question ; but the condition of skin which makes 
epithelioma more than possible certainly predisposes to its occurrence. 



34 ORIGINAL ABSTRACTS. 

The question can be better put by asking whether actinic rays of light 
unfavorably influence, not all, but certain sensitive skins at definite 
ages of the body in the direction of the epitheliomatous metamorphoses? 

It is to be remembered that pigmentation, especially hyperpigmenta- 
tion, admittedly furnishes a valuable protective screen for the body. 
The dark skins of the Asiatic and the African possess for them a great 
protective value against heat and light. The Albino, without trace of 
pigment either in the skin or the choroid coat of the eye, is notoriously 
feeble of body and short-lived. Hektoen states that black rats are more 
resistant than gray, and gray rats than white to anthrax. In this con- 
nection it is interesting to note that Gaylord and his colleagues in study- 
ing Jensen's adenocarcinoma obtained their remarkable results after 
experimentation with white mice only. The researches of Loeb, Gru- 
ber, Dubois and others on the orientation of plants and animals throw 
some light on this question. They indicate that heliotropism is influ- 
enced largely by the more refrangible rays of light; . . . that at 
a constant intensity light operates as a continuous source of stimulation ; 
. . . chemical rays playing upon the sensitive and unprotected skin 
produce in order — first, hyperemia; second, pigmentation; third, atro- 
phy ; fourth, cancerosis. The first two changes are obviously protective 
in character. 

The action of the Finsen light upon the skin produces a reactive 
hyperemia, though the technique of its application requires that the 
area to be treated should be made as exsanguine as possible to permit 
the passage of rays to the skin. The action of the ,r-rays upon the 
cutaneous surface is similar to that of the ultraviolet frequencies. 
. . . The hyperemia is followed by well-marked pigmentation, more 
conspicuous in some cases than in others. Later, in the results of 
actinic ray bombardment, atrophy may result, the overstimulated pro- 
toplasm losing its vitality, the cells and their nuclei shrinking while 
phagocytosis, as in other cases, disposes of the epithelial cells. But 
hyperkeratosis, and finally cancerosis may occur. The .r-ray produc- 
tion of cancer of the skin reported by Mendes, Da Costa, White, 
Bowen, Pusey and others is established by other incontrovertible evi- 
dence. Fortunately the beneficent use of the rays far outranks the 
exceptional catastrophe in which a disastrous result is produced. 
Doctor Ormsby has noticed that patients who burn in sunlight are 
burned by ^-rays. The beneficial effects of all these rays occur when 
the stimulation is pushed to the point of cell shrinkage and not farther. 

The doctrine that light is capable of exciting in animal tissue a 
series of changes which may terminate fatally is not inconsistent with 
the facts of science. Beneficent as they are shown to be in much that 
relates to both the genesis and conservation of life, heat, light, and 
electricity, interchangeable modes of motion have each a stroke where- 
with slowly or swiftly they may destroy that life." 

Following are the doctor's conclusons : 

(i) The skin of the human body in a certain proportion of indi- 



DIET IN EPILEPSY. 35 

viduals, and in those only, is hypersensitive to the action of the actinic 
rays of the spectrum. 

(2) This hypersensitiveness may be exhibited in the production of 
either hyperemia, pigmentation, telangiectasis, atrophy, hyperkera- 
tosis, or cancerosis of the skin, or by all at times in a determined order 
of succession. 

(3) In the form of childhood cancerosis, known as xeroderma pig- 
mentosum, pigmentation, telangiectasis, atrophy, hyperkeratosis, and 
cancerosis of the skin resulting from exposure to rays of light, are 
exhibited early in life, instances of this disorder being exceedingly rare. 

(4) Pigmentation, telangiectasis, atrophy, hyperkeratosis, and can- 
cerosis of the skin occur in adults much more frequently than in child- 
hood, reaction to the play of actinic rays of light upon the surface being 
chiefly determined after the middle periods of life have been reached. 

(5) Physiological pigmentation of the skin in the colored races 
seems to furnish relative immunity against cancerosis of that organ. 

(6) The colored races apparently suffer less than the whites from 
cancer of other organs than the skin. This relative immunity may be 
due to the protection from actinic rays of light furnished by the pig- 
ment of the integument. 



NEUROLOGY. 

By DAVID INGLIS, M. D.. Detroit, Michigan. 

PROFISSOS or KIRVOUS AND KBNTAL DISHASSS IN THB DBTKOIT COLLBCB OF MBDICINB. 

AND 

IRWIN HOFFMAN NEFF, M. D., Pontiac. Michigan. 

ASSISTANT PHYSICIAN AT THB BASTBRN MICHIGAN ASYLUM. 



THE DIET IN EPILEPSY. 



RoSANOFF (Journal of Nervous and- Mental Disease, December, 
1905, Volimie XXXII, Number XII). The writer quotes authorities 
in proof that certain articles of diet may cause a material change in the 
syndrome of epilepsy. The paper is founded on eleven cases. The 
results were obtained from five experiments, a definite number of 
epileptics being placed on a prescribed diet, and accurate clinical 
observations taken. 

His results are summed up as follows : "Experiments one and two 
proved that the effect of a mixed diet in epilepsy differs in no way 
from that of a vegetable diet containing the same quantities of proxi- 
mate principles. Consequently any lingering belief that animal iood 
has any effect as such is to be definitely discarded. Experiments three 
and four prove that the quantity of proteids in the diet has a decided 
influence on the manifestations of epilepsy. If it i<' either above or 
below the indispensable minimum the severity of the disease is 
increased. Experiment five shows that if the diet of an epileptic is 
made to contain a large excess of proteid and practically no carbohy- 



36 ORIGINAL ABSTRACTS. 

drates, so that the organism is compelled to use proteid material in 
place of carbohydrate material, the number of convulsions increases 
enormously and there is a general aggravation in the physical and 
mental condition of the patient." 

In conclusion the author advances a theory as follows : "That just 
as the organism of the diabetic is unable to properly utilize carbohy- 
drates, so the organism of the epileptic cannot take care of proteid 
material as it is taken care of by the normal organism." 

The therapeutic indication, he believes, is clear, and he expresses 
it as follows : "Carbohydrates and fats are to a certain extent capable 
of replacing the proteids in the diet. The epileptic j)atient, then, should 
receive the largest amount of carbohydrates and fats that he can 
assimilate without inconvenience, and the smallest amount of proteids 
which is compatible with the preservation of the nitrogenous equi- 
librium ; that is to say, the amount of nitrogen ingested with the food 
must not be allowed to fall below the amount excreted, for then the 
thing is overdone, a condition of proteid starvation is established, the 
general health of the patient suffers, and his disease becomes 
aggravated." i. h. n. 

THERAPEUTICS. 

By DELOS LEONARD PARKER, Ph. B., M. D.. Detroit, Michigan. 

LBCnmiR OH MATBRIA MBDICA IN THB DBTROIT COLLBGB or MBDICIMB. 



THE PRESENT STATUS OF SERUM THERAPY. 

Ezra Read Larned, M. D., in The Therapeutic Gazette for Sep- 
tember, 1905, discusses the subject of serum therapy. He first sepa- 
rates the different sera into two groups as follows : ' Curative sera and 
diagnostic sera. He further classifies sera according to their efficacy 
as curative agents. 

In the first group he places those whose efficacy has been demon- 
strated beyond reasonable doubt, such as antidiphtheric, antitetanic, 
antiplague, antistreptococci and serum for exophthalmic goitre. 

In the second group are sera whose value appears likely or possible, 
but in support of which there is not yet sufficient evidence to warrant 
their inclusion in Class I. These contemplate hay-fever, antityphoid, 
antitubercle, antirabic, and antivenene sera, and tuberculin. 

In the third group are those sera whose value is questioned by a 
majority of observers. These are antipneumococcic sera, antiscarla- 
tina sera, antidysenteric sera, antivarioloid sera, antitoxin for cerebro- 
spinal meningitis, serum for rheumatism, serum for syphilis, and sera 
for anthrax, cancer, and leprosy. 

Of the curative sera Doctor Lamed states that antidiphtheric serum 
justly holds the highest place, and if used early and in sufficient quan- 
tities can be counted on to overcome every case of the disease. 

Of antistreptococcic serum not so much can be said. On the whole 



CLINIC IN PSYCHIATRY. 37 

the Doctor thinks the result obtained from this serum has been dis- 
appointing. This result may be caused by the circumstance that pure 
streptococcic infection is rare as compared with mixed infection. Where 
the infection has been purely streptococcic the result has been good. 

Antitetanic serum gives good results when used early and in large 
quantities. Professor Ehrlich is quoted as saying that initial doses of 
thirty cubic centimeters or more followed by frequent subsequent doses 
of ten or twenty cubic centimeters may be depended on to produce 
results satisfactory in character. Authorities differ as to the mode of 
administering this serum. Among the methods mention is made of 
subcutaneous, intravenous, intraneural, intracerebral and intraspinal 
by lumbar puncture. The use of dried antitetanic serum as a dusting 
powder in dressing suspected wounds is recommended. 

Antiplague serum is said to be of positive value when given in large 
doses — from sixty to one hundred and fifty cubic centimeters, or even 
three hundred cubic centimeters, preferably intravenously. 

In exophthalmic goitre the specific seruhi is said to be so encourag- 
ing in results that its use is to be recommended. 

Hay-fever serum the doctor thinks is of great but of uncertain 
value. The remedy may be administered hypodermically but better 
results are usually obtained by having the patient himself apply the 
serum to the nasal mucous membrane by means of a dropper when 
irritation is noticed. In the use of this serum the good effects are not 
long maintained. 

Tuberculin is spoken of as an experimental product and antitubercle 
serum as being worthy of more extended trial. Serum for rheuma- 
tism, secured from horses treated with streptococci, isolated from the 
throat of the rheumatic sufferer, gives promise of being valuable. 

The sera whose standing as curative agents has not been established 
are mentioned above. 



EDITORIAL COMMENT. 



THE NEW CLINIC IN PSYCHIATRY AT THE UNIVERSITY 

OF MICHIGAN. 

The first University Psychopathic Hospital and Clinic established 
in America for the observation, care, and treatment of persons afflicted 
with incipient insanity, and for borderland cases which cannot be strictly 
regarded as insane, although manifesting various phases of mind dis- 
turbance, is now in operation as a component part of the medical equip- 
ment of the University of Michigan, under the directorship of Doctor 
Albert Moore Barrett, late pathologist of the Massachusetts Hospital 
for the Insane, located at Danvers, and assistant in neuropathology in 
the Harvard Medical School. The governing power of the institution 



38 EDITORIAL COMMENT. 

is vested in a joint committee, whose appointment rests with the Univer- 
sity Regents and the executive bodies of the various state asylums for 

the insane. 

♦ * * 

The institution was created by enactment of the legislature of 190 1. 
A supplementary act of the legislature of 1905 established relationship 
between the hospital and asylums, and henceforth the two forces will 
render combined service in the management of the new institution. 
Another provision of the law invests the director of the Psychopathic 
Hospital with the title of pathologist to the several asylums, and pro- 
fessor of neuropathology in the medical department of the University. 
In the capacity of pathologist a requirement contemplates definite 
knowledge by this official concerning the medical conduct of the 
asylums throughout the state, exacting frequent visits for the purpose 
of encouraging the medical staffs to pursue careful scientific study of 
the various forms of mental disease peculiar to the inmates. As pro- 
fessor in the University the director is required to impart instruction 
in clinical psychiatry and conduct the laboratory for psychopathic 
research which was founded in connection with the hospital, the main- 
tenance of which is insured by an annual appropriation of five thousand 
dollars granted by the legislature. 

m n^ m 

The objects sought to be attained by founding the institution con- 
template more accurate investigation relative to the nature and causes 
of insanity. The idea is to make the new acquisition a central patho- 
logic institute which will* afford not only expert skill in nervous diseases 
by reason of cooperation with the asylums of the state, but possess, 
in consequence of University connection, the additional advantage of 
specialists in every branch of medicine. It will give asylum physicians 
opportunity to pursue research work at the clinical laboratory, and 
qualify students to render intelligent service as asylum physicians or 
general practitioners. It will exert influence in the direction of cre- 
ating a correct public sentiment regarding psychopathic ailments and 
of promoting rational ideas concerning the prevention of such diseases. 

* 4t :|c 

The Psychopathic Hospital is especially designed and equipped for 
the study of acute cases of mental disturbance. It has accommodation 
for forty patients — twenty of each sex. This limited number permits 
the alienists to exercise close observation of every subject committed 
for treatment. The clinical laboratory affords apparatus for conducting 
elaborate investigation bearing on the phenomena of mental disease, 
and the study of any anatomical material supplied by the various 
asylums will be pursued according to methods afforded by the most 
modern neuropathological technic. There will likewise be installed in 
the building a complete hydrotherapeutic apparatus modeled after the 
design of Doctor Baruch, together with apparatus for administering 



CLINIC IN PSYCHIATRY 39 

electrotherapeutic treatment whenever this particular therapeusis is 
indicated. 

4t * * 

The Psychopathic Hospital affords a place where persons may be 
sent for short observation pending opinion as to the necessity of com- 
mitting them to one of the state asylums, or as to whether preliminary 
treatment at 'this institution will obviate the necessity for such commit- 
ment. Thirty-eight patients have already been registered and applica- 
tions for a number of others are under consideration. Thirty-two of 
the patients were transferred from the state asylums at the opening of 
the hospital, and the remainder are voluntary patients or those com- 
mitted as private and county charges. In addition to the director there . 
is constantly in attendance the resident physician, Doctor George Milton 
Kline. Cases are continually presenting in which the question must 
be determined whether the condition is onp of neurasthenia or of more 
serious transitional form of mental disturbance, and physicians through- 
out the state are advised that patients may be sent to the institution 
according to three processes. 

♦ * * 

(i) In cases where application shall be made under the statute to 
send persons claimed to be insane to one of the asylums in the State 
of Michigan, the Judge of Probate, before whom said application is 
pending, may require the assistance of three competent and skilled 
physicians who shall investigate the condition of said person and report 
the same to the Judge of Probate in writing and if said Judge of Pro- 
bate upon investigation ascertains that there are present in *the con- 
dition of the patient such features as render detention in a psychopathic 
hospital for a brief period advisable as a precautionary or curative 
measure, or if from such investigation said Judge of Probate shall be 
of the opinion that the case requires the services or treatment of special- 
ists in the treatment of diseases other than those of the nervous system, 
he shall pass an order directing thaf such patient shall be transported 
for treatment to the Psychopathic Hospital of the University of Michi- 
gan. If the patient shall continue insane after any such special treat- 
ment he may be removed to and confined in such asylum of the State 
of Michigan as the Probate Judge may decree in his order of committal 
to the Psychopathic Hospital. 

4c 4t 4t 

(2) In case the Superintendent of either of the asylums for the 
insane shall be of the opinion that the condition of mind of any person 
confined in such asylum is such that it might be advisable that the 
patient be sent to the Psychopathic Hospital he shall cause such person 
to be conveyed thereto. If such patient shall be restored to sanity while 
in the said institution he shall be discharged, but in case such patient 
shall be found incurable, the Superintendent of the University Hospital 
shall cause said person to be returned to the asylum from which said 
person was received, the charges for the care, maintenance and trans- 



40 EDITORIAL COMMENT. 

portation to be paid by the county or by the state, depending upon 
whether the patient is a county or a state charge. 

♦ ♦ 4k 

(3) Persons may ccwnmit themselves as voluntary patients under 
the same provisions as apply to such commitments to the state asylums. 
The exact charge for maintenance cannot be determined at this time, 
but will depend upon the average per capita cost for maintaining the 
hospital, and will vary with the number of patients present in the hospi- 
tal at such time. It will be somewhat higher than for the care of patients 
in the state asylums, but will be kept as low as is consistent with proper 
treatment and the purposes for which the Psychopathic Hospital was 
established. It will probably be about the same as is charged in the 
other hospitals of the University, which at present is about seven dol- 
lars and fifty cents per week. Private patients may be admitted at any 
time under any of the foregoing provisions. In such cases the joint 
board in control of the Psychopathic Hospital has fixed the rate of 
fifteen dollars per week, and requires the friends of each private patient 
to furnish a bond in the penal sum of one thousand dollars, on substan- 
tially the same conditions, so far as applicable, as those required by the 
Michigan asylums for the insane. There shall be paid by such private 
patient, or by his or her friends, at the time such patient is admitted, as 
an advance pa>Tnent toward the support of such patient, the sum of 
fifty dollars. 

ANNOTATIONS. 



THE TREATMENT OF SARCOMA WITH MIXED TOXINS. 
CoLEY, in a contribution to the recent meeting of the Southern Sur- 
gical and Gynecological Association, detailed his experience with a mix- 
ture of the toxins of erysipelas and the bacillus prodigiosus in the treat- 
ment of sarcoma. While the doctor had, until recently, employed the 
mixture only in such cases as were not amenable to surgical treatment, 
his success with a large variety of cases has led him to advocate its 
administration in all forms of the disease wherein primary surgical 
operations have been performed. Very minute doses should be 
employed in this class of cases — only large enough to produce slight 
reaction. Before inaugurating radical measures, such as limb amputa- 
tion, it is well as a final resort to employ the toxins, since in a number 
of patients disappearance of the tumor and consequent recovery resulted 
from their administration. In arriving at his conclusion the author 
observed the recovery of twelve patients, eight of whom were alive and 
well for from three to six years after treatment. Eight of the above 
cases were of the round-cell variety; two of the spindle-shape; while 
the tissue of the remaining two patients was not subjected to micro- 
scopic examination. But three of these cases were personal. How- 
ever, Coley has detailed the result of the treatment in thirty-four cases 
under his direct supervision, with which he experienced but five 



TREATMENT OF MAL DE MER. 41 

reverses — recurrence of the tumor and subsequent death. While the 
demise of this quintet is to be regretted, it would seem to furnish proof 
conclusive of the correctness of the diagnoses. The cases under 
Coley's personal study, and those which he has been able to observe out- 
side his own practice, embodied (i) round-celled, (2) mixed-celled, (3) 
spindle-celled, and (4) endothelioma. 



PEDAL CHARACTERISTICS OF DIFFERENT PEOPLES. 
Comparative study of the foot in barefoot and shoewearing peoples 
is detailed by Doctor Hoffmann in a late issue of the Quarterly Bulletin 
of the Medical Department of Washington University, The relative 
length of the foot in either class is practically the same, and in both 
classes the form, function, and range of motion, up to the time of shoe 
adoption, are markedly similar. Deformation and inhibition of function 
follow the inauguration of shoewearing. The pedal inheritance of the 
shoewearer's progeny, so far as form is concerned, is synonymous to 
the heritage acquired by the offspring of barefoot races, the natural 
symmetry, however, being altered after encasement in modem foot- 
wear. The theory is advanced that the strength and usefulness of the 
foot is not dependent on the height and shape of the longitudinal arch, 
and breaking and lowering of the arch to the degree of flat-footedness is 
rarely resultant from weakness at this point. Moreover, no relation- 
ship exists between the gait and the height of the arch. 



PHYSIOLOGIC FUNCTION OF THE PITUITARY BODY. 
Anent the various theories that have been expounded regarding the 
origin of sleep, a recent contribution by Doctor Alberto Salmon, to the 
Italian Medical Congress, is of vital interest. The opinion of this 
scientist is that an internal physiologic secretion from the pituitary 
gland produces somnolence. He further expresses the idea that the 
bromine contained in the pituitary structure is the active agent in sleep 
production, and cites the experience of the profession in the employ- 
ment of the glandular extract in insomnia to substantiate his hypothesis. 
Somnolence is often associated with certain pathologic conditions of the 
gland, and the reverse may be true, since in many cases wherein tumor 
is present, in Graves' disease, in cases of poisoning with consequent 
inhibition of the secretion, and in many other conditions, including 
senility, insomnia is the prevailing symptom. While sleeplessness is 
said to result from an insufficient flow of the pituitary secretion, an 
increase of the fluid by the ingestion of such toxic drugs as pilocarpine 
invariably produces a condition of profound sleep. 



THE MECHANICAL TREATMENT OF MAL DE MER. 

A MECHANICAL dcvicc lately invented by Doctor Carl Brendel, a 
Russian physician, promises relief from seasickness to individuals not 
proficient in nautical accomplishments. While the condition has been 
combatted more or less successfully by the administration of drugs and 



42 EDITORIAL COMMENT. 

chemicals, not many remedies of a mechanical nature have been offered 
to the maritime traveler, and hence announcement of the latest preven- 
tive will be accorded consideration. The novelty is in the form of a 
chair, the seat, arms, legs, and back of which are freely movable. The 
idea of the designer is that a counteraction of the long pitching move- 
ment of the sea-going vessel, by the short up and down and occasional 
backward movement of the chair — the motive power of which is fur- 
nished by a small electric motor — tends to overcome the seasickness. 
The inventor does- not claim for his chair immunizing properties, nor 
does he even venture that it will effect permanent cure, but those who 
have had opportunity to test its virtues declare that a few moments of 
repose in the chair offer relief from the unpleasant symptoms. 



CONTEMPORARY. 



PHYSICIANS AND PHILOSOPHERS. 

[professor CHARLES WILLIAM SUPSR, OP OHIO UNtVRRSITT, IN POPULAR SCIENCE MONTHLY.] 

Although the initial assonance of physician with philosopher 
is purely accidental, it is nevertheless a fact that philosophy and the 
healing art or medical science have been closely associated with each 
other from their earliest beginnings. It cannot but be regarded as a 
singular coincidence that for two and a half millenniums physic and 
philosophy, the practitioners of the healing art and the real or professed 
lovers of knowledge, have been more or less intimate friends. At the 
beginning they seem to have found themselves in each other's company 
almost by chance; then by a sort of elective affinity like that which 
often springs up between persons of opposite sex whose paths in the 
ordinary course of events incidentally crossed each other, to have 
discovered that they could make the rest of the journey together to 
reciprocal advantage. 

Herodotus, the Father of History, was a native of Halicarnassus, 
and Hippocrates, the Father of Medicine, his younger contemporary, 
first saw the light on the island of Kos, only a few leagues distant. 
Born in the same year with Hippocrates was the philosopher Diogenes, 
of Apollonia in Crete, whose few literary remains not only attest his 
interest in human anatomy, but also furnish proof that he early came 
under the influence of the Ionian thinkers. Though never regarded 
as a physician, but only as a philosopher, he tells us in one of the very 
brief fragments that have been preserved that the veins of the human 
body are divided into two branches ; that they pass through the abdom- ' 
inal cavity along the backbone, one on the right side, the other on the 
left, into the legs y and that two branches pass into the head. He then 
goes on to describe the course of the blood-vessels and their ramifica- 
tions as far as the ends of the toes, the fingers, and so on. It may 
safely be assumed from this fragment that Diogenes gave much atten- 
tion to the structure of the human body. 



PHYSICIANS AND PHILOSOPHERS. 43 

In the southwestern portion of Asia Minor, the disciples of 
Asclepias or iEsculapius had several therapeutic establishments, and 
it is in connection with these that we discover the first signs of what 
may be called the healing art in the entire ancient world. 

It was especially the priests of the temples of Kos and Knidos who 
cultivated a primitive and simple medical science in connection ynth 
their service of the god. In this part of Asia, also, philosophy took 
its rise. For not only was Hippocrates a philosopher as well as a 
physician, but the same affirmation can be made of a considerable 
number of Greek thinkers. Diogenes has just been mentioned. More- 
over the two lines of investigation were often parallel in other parts 
of the ancient world. Empedocles who was a full generation older 
is supposed to have been a physician. Pythagoras, who lived still 
earlier, though perhaps not a physician in the strict sense of the word, 
gave, according to tradition, no little attention to the laws of health 
and formulaited a mmiber of precepts supposed to be conducive to its 
preservation. Plato, though not a special student of the healing art, 
shows in many passages of his Dialogues, a considerable degree of 
familiarity with the subject. Aristotle was the son of a physician and 
was indebted to his father not only for much of his knowledge, but 
also for his interest in natural history; while his pupil Theophrastus 
is regarded as the father of medical botany. Among the Romans we 
find Pliny paying a good deal of attention to facts or supposed facts 
in the realm of medicine. The same thing is true of Seneca and still 
more of Vitruvius, though it would perhaps be as far astray to call 
him a philosopher as a physician in the strict significance of the terms. 
Toward the latter part of the second century we are carried back again 
to Asia Minor to find in Galen of Pergamus, not only a distinguished 
writer on philosophical subjects, but a man whose reputation as a 
physician is fully equal to, if not greater than, that of Hippocrates, 
notwithstanding that he was a man of less native capacity. It may 
be confidently affirmed that Hippocrates, Celsus and Galen represent 
the entire healing art until modern times. With respect to Cornelius 
Celsus, who lived in the reign of Tiberius and who occupies an impor- 
tant place in the history of ancient medicine, it mu.«t be said that it 
is uncertain whether he was really a physician. It is rather more 
than probable that he was a savant. On the other hand, the question 
is raised. Why would any one but a practical physician compile a 
medical work? Could any other person do it successfully? Another 
singular fact that has added to the difficulty of defining Celsus' posi- 
tion is that even as late as the age in which he lived nearly all the 
physicians in Rome were Greek freedmen. At any rate the work of 
Celsus at once sprang into prominence, and though it is only part of 
an encyclopedic compilation, nothing else remains at the present day. 
As*is the case with not a few other works of antiquity, its connection 
with modem times hangs by the slender thread of a singfle manuscrpit 
from which all later copies have been made. This portion of the 
encyclopedia of Celsus has also an important historical value since it 



44 ^ MEDICAL NEWS. 

gives brief sketches of more than seventy physicians who had lived 
before his time and had attained a certain degree of eminence. It 
had not escaped his observation that only persons of mediocre ability 
are loth to admit errors, while the reverse is true of genius, since there 
still remains a large residuum of truth in its possession. 

[TO BE CONTINUED.] 



MEDICAL NEWS. 



A PHYSICIAN GRANTED PATRONYMIC APPELLATION. 

Doctor Charles Beylard Nancrede, Professor of Surgery in the 
University of Michigan, recently petitioned the Probate Court of the 
County of Washtenav^^ for a change of his name, and he will hence- 
forth bear the appellation of "Charles Beylard Guerard de Nancrede." 
The application recounts the information that the grandfather of the 
petitioner bore the cognomen of "Paul Joseph Guerard de Nancrede," 
but discarded the "de" at the time of his naturalization as an American 
citizen; that the father, who was bom in 1799, was baptised "Thomas 
Dixey" and never utilized the family patronymic "Guerard de Nan- 
crede," simply abridging the name to "Nancrede." Restoration of the 
name to its original form was desired for family reasons. 



THE DEMISE OF DE WECKER. 

Baron De Wecker, of Paris, who died recently, was seventy-three 
years of age. Through his death the world has lost one of the "Fathers 
of Ophthalmology" and one of the greatest ophthalmic surgeons of 
his day. .He was oculist to Napoleon III, and to the Spanish Court, 
and was also von Graefe's chief of clinic and associate of Artt and 
Jaeger. He succeeded Desmarres in Paris and introduced the ophthal- 
moscope in France. The French government made him Grand Officer 
of the Legion of Honor, and he received decorations from nearly every 
crowned head of Europe, 



MINOR INTELLIGENCE. 

Our printing house is recovering from the effects of the recent 
printers' strike and succeeding numbers of this journal will be issued 
promptly. 

The Hungarian government has awarded one thousand kronen 
to Professor Kohut, of Konigsburg, for his prize essay on the treat- 
ment of trachoma. 

According to report the original copy of Harvey's paper on the 
"Circulation of the Blood" was sold recently for £30. The manuspript 
was written in 1628. 



MINOR INTELLIGENCE. 45 

The Western Penitentiary of Pennsylvania is threatened with an 
q)idemic of smallpox. A prisoner who has been incarcerated for over 
a year has mysteriously contracted the disease, and every precaution is 
being exerted to protect the nine hundred fifty inmates of the prison. 

The government contemplates the erection of a $400,000 hospital 
for the Army and Navy. Doctor Louis de Clermont, of Washington, 
has secured a site of over six hundred acres of ground in Illinois, and 
a structure sufficiently large to accommodate three thousand patients 
mil be erected thereon. 

Minnesota has a law compelling physicians to report to the 
register of deeds of their county, all accidents in which the victim is 
disabled for a period of two weeks or longer. Failure to comply with 
the enactment is punishable by a fine of one hundred dollars or impris- 
onment for a period of six months. 

An interesting case of premature maternity is reported from 
Bristol, Tennessee. The mother is a colored girl, ten years of age, a 
native of Virginia, and the infant weighs eight pounds. It is said 
that chances for its survival are excellent and that the mother has 
experienced a complete recovery from the early parturition. 

Spring Beach, a suburb of Seattle, Washington, is to have a new 
$30,000 sanatorium. A four-story structure is contemplated, and as 
the promoters have already secured one hundred acres of land, ample 
grounds are assured. The institution will afford accommodation to 
five hundred patients, and will be under the supervision of a staff of 
fifteen physicians. 

Brooklyn has a novel institution in the form of a public library for 
the blind. Inasmuch as raised letter books are quite expensive, and as 
few blind persons can afford indulgence in them, the library is a very 
welcome acquisition to the educational system of the city. Most of the 
volumes deal with nature or light emotional subjects, as sightless indi- 
viduals prefer this variety to works of more profound type. 

The war department has provided for the establishment of a chair 
of military hygiene at the West Point Military Academy. The cadets 
will receive sufficient medical knowledge to enable them to care for 
troops from a hygienic standpoint, and to administer relief in superficial 
injuries. The founding of the chair was doubtless prompted by the 
remarkable results obtained by Japanese military surgeons in the late 
war. 

The German Rontgen Society has issued an inaugural volume of 
proceedings, detailing the work of the first congress of .r-ray workers. 
The book is divided into five parts enumerating the various features 
of the meeting. The first section is merely a compilation of the physi- 
cians who were in attendance; section two is devoted to exhibits; 
section three contains the papers read and the discussions thereon; 
and sections four and five are devoted to a history of the organization, 
and the publication of communications. 



46 MEDICAL NEWS. 

Professor Terriani estimates that eighty per cent of the child 
criminals of Italy owe their vicious instincts to unsuitable environment 
and insufficient educational advantages. He further states that thirty 
per cent of the criminals of the kingdwn have not yet reached legal age, 
and that of this number eighty-five per cent are thieves. 

Efforts are being exerted toward the establishment of a medical 
college for the United Provinces of India, as a memorial of the visit of 
the Prince and Princess of Wales to the Peninsular. The question has 
long been agitated and it is probable that matters have at last reached 
a focus, as each province is endeavoring to outdo the other in the matter 
of support. 

The consolidation of the Medical and Surgical Monitor and the 
Centred States Medical Magazine has been effected at Indianapolis, 
the new publication being known as the Central States Medical 
Monitor, Doctors S. E. Earp and S. P. Scherer will comprise the 
editorial staff. The Monitor is the latest acquisition to the field of 
independent medical journalism, and we wish it success. 

The National Association for the Study of Epilepsy has announced 
its intention to award a prize of $300 for the best original paper on the 
"Etiolc^ of Epilepsy." Essays must be submitted for approval before 
September i, 1906, as the prize essayist will be announced in November. 
Physicians desiring information regarding the award may communicate 
witii the president of the association, Doctor W. P. Spratling, of Sonyca, 
New York. 

The twenty-ninth annual meeting of the American Dermatological 
Association was held in New York City on December 28, 29 and 30, 
1905. The following officers were elected for the ensuing year: Presi- 
dent, Doctor Milton B. Hartzell, of Philadelphia; vice-president, 
Doctor T. Caspar Gilchrist, of Baltimore; secretary-treasurer, Doctor 
Grover W. Wende, of Buffalo. Cleveland was designated as the meet- 
ing place foV 1906. 

In accordance with an order from the Commissioner of Immigration 
of the port of New York, saloon and second cabin passengers will 
henceforth be subjected to examination by the government physicians. 
Heretofore the order affected only steerage passengers, but owing to 
rejected immigrants taking advantage of legal inadequacy by returning 
as saloon passengers the regulations in regard to such persons were 
made more stringent. 

Boston has a new hospital for the treatment of diseased horses, 
dogs, cats, and other domestic animals. The institution is to be 
equipped in the most approved fashion — operating rooms, exercising 
paddocks, private wards, and baths being stipulated in the architect's 
plans. A free clinic will be conducted weekly for animals belonging 
to the poorer classes. The hospital is under the direction of Samuel 
F. Wadswords, M. D. V., a graduate of the Harvard Veterinary 
School. 



INTERNATIONAL CLINIC. 47 

Paul Revere, the Revolutionary patriot, according to the follow- 
ing announcement taken from an old copy of the Boston Gazette and 
Country Journal, must have been a dentist : "Whereas, many persons 
are so unfortunate as to lose their Fore-teeth by Accident and other- 
ways, to their great Detriment, not only in Looks, but speaking both 
in Public and Private : — This is to inform all such that they may have 
them replaced with artificial ones, that looks as well as the Natural & 
answers the end of Speaking to all Intents, by Paul Revere, Goldsmitji, 
near the head of Dr. Clarke's Wharf, Boston. All Persons who have 
had false Teeth fixt by Mr. John Baker, Surgeon Dentist, and they 
have got loose (as they will in time), may have them fastened by the 
above who learnt the Method of fixing them from Mr. Baker." 



RECENT LITERATURE. 



REVIEWS. 

COAKLEY'S LARYNGOLOGY.* 

The popularity of the two preceding editions is suflScient proof of 
the value of this work. In its third edition it has been revised, enlarged 
and brought completely up-to-date. Due to its completeness and to 
its ccMnpact form it serves equally well as a text-book for students and as 
a reference book for practitioners and specialists. The most important 
revision in this last edition is that of the chapter on the "Diseases of the 
Accessory Sinuses." This has been entirely rewritten and gives very 
clearly the author's standpoint upon this very important division of 
the specialty. 

Throughout the work is well written and well illustrated and offers 
a consistent and satisfactory exposition of its subject matter. 

*A Manual of Diseases of the Nose and Throat. By Cornelius G. 
Coakley, A. M., M. D., Professor of Laryngology in the University and 
Bellevue Hospital Medical College ; Laryngologist to Columbus Hospi- 
tal, et cetera, New York. New (third) edition, revised and enlarged. 
In one i2mo. volume of 594 pages, with 118 engravings and five colored 
plates. Qoth $2.75 net. Lea Brothers & Company, Publishers, Phila- 
delphia and New York, 1905. - R. b. c. 



INTERNATIONAL CLINICS.* 
The latest volume of this well-known series gives us as usual a valu- 
able collection of sound practical papers, with a few theoretic or sugges- 
tive ones. Among the former may be mentioned a very useful article on 
"Radiothcirapy," by George C. Johnston; one on the "Symptomatic 
Treatment of Tuberculosis," b); Noble P. Barnes ; "Membranous Colic," 
by Alexander McPhedran ; "Addison's Disease," by Edward F. Wells ; 
"Cancer of the Bile-Duct," by F. Parkes Weber and E. Michel ; "Frac- 



48 RECENT LITERATURE. 

ture of the Patella," by J. Sherman Wainwright ; "Ethyl Chlorid Anes- 
thesia," by Thomas D. Luke. Richard Kretz gives a succinct account 
of "Cirrhosis of the Liver," in its anatomic relations. The articles of 
Albert Robin, on the "Action of Metallic Ferments on Metabolism and 
Pneumonia," and Professor Teissier on "Opotherapy in Renal Insuffi- 
ciency," are interesting. Sanger Brown has a thoughtful article on the 
"Early Stages of Acute Poliomyelitis," so often overlooked in practice, 
and there are others in Ophthalmology and Rhinology. John W. Wain- 
wright's article on "Serum Therapy" is brief to the danger point. If 
vaccination is to be includedin such an article it would seem worth 
while to give some explanation of unusual views that appear, such as 
the one that "true animal vaccine" and "variola vaccine" are different, 
or are distinguished in practice, or that "pulp consists of proliferated 
epithelium." 

On the whole the volume is not quite up to the standard of some of 
its predecessors, but well deserves the continued popularity acquired by 
the series. G. d. 

*A Quarterly of Illustrated Clinical Lectures and Especially Pre- 
pared Original Articles, et cetera. Edited by A. O. J. Kelly, A. M., 
M. D., Philadelphia. Volume III. Fifteenth Series, 1905. J. B. Lip- 
pincott Company. 

HAREMS TEXT-BOOK OF PRACTICAL THERAPEUTICS.* 

The eleventh edition of this work, enlarged, revised and largely 
rewritten is before the profession. Among the changes that have been 
made in bringing out this edition the changing of the doses of drugs to 
conform to the new Pharmacopeia is the most important. To the physi- 
cian this is a labor-saving provision, to the patient a guarantee that his 
medicines are efficient and safe, and to the student a path that leads m 
the way he should go. 

The volume contains two sections, one dealing with drugs, remedial 
measures and foods, the other with the use of drugs, in treating disease. 
The book has the good points of its predecessors and several other 
good points in addition. 

Hare's Therapeutics has come to take on some of the characteristics 
of a government report. A new edition is looked for yearly and the 
opinions and the conclusions expressed are viewed as coming from one 
in authority. D. L. p. 

*A Text-Book of Practical Therapeutics, with Especial Reference 
to the Application of Remedisil Measures to Disease and their Employ- 
ment upon a Rational Basis. By Hobart Amory Hare, M. D., B. Sc, 
Professor of Therapeutics and Materia Medica in the Jefferson Medical 
College of Philadelphia, Physician to the Jefferson Hospital, et cetera. 
New eleventh edition, enlarged and thoroughly revised to accord with 
the eighth decennial revision of the United States Pharmacopeia, 1905. 
In one octavo volume of 910 pages, with 113 engravings and four 
colored plates. Qoth, $4.00, net; leather, $5.00, net; half morocco, 
$550, net. Lea Brothers & Company, Philadelphia and New York. 




MOSKS GLNN. 



A PROFESSIONAL MEDICAL JOURNAL. 



VOLUME XXVIII. FEBRUARY. 1906. . NUMBER II. 



ORIGINAL ARTICLES. 



MEMOIRS. 



THE LIFE AND CHARACTER OF MOSES GUNN. 

A. M., M. D., LL. D.* 

By C. B. G. de NANCR^DE, A. M., M. D., LL.D., Ann Arbor, Michigan. 

PROnSSOIt OF SUKGERT AND CUNICAL SUKGBXT, AND DIKBCTOR OF TMB SURGICAL CLINICS, IN 
THB UNIVSRSmr OF MICHIGAN. 

Mr. President, Members of the Faculty, Students of the Department of 
Medicine and Surgery, Ladies and Gentlemen: 

While perhaps it is appropriate that to the present incumbent of the 
Chair of Surgery has been deputed the task of presenting to you a few 
of the salient facts in the life and character of the first Professor of Sur- 
gery in this institution, I cannot but feel that it is most unfortunate that 
one so little associated with him personally, had to be selected. This 
man, to whom the medical school owes so much, who in every sense of 
the word was one of our Founders, can hardly have justice done him by 
one who never worked with him in those early days when, as he taught 
others, he learned himself, day by day, how the facts of medical science 
could best be conveyed ; for, as you will see, he was practically without 
training as a teacher when at one bound he was called upon to fill two 
of the most important chairs in the Medical Department of the Univer- 
sity of Michigan, and that too, in a school depending entirely for its 
future success upon the ability of its untried faculty. How well he 
succeeded, it Will be my endeavor to show you, and to point out those 
qualities by means of which this success was achieved. 

The subject of our memoir was born in East Bloomfield, New York, 
the youngest of the four children of Linus Gunn and Esther Brunson. 
His parents were of Scotch ancestry, Moses taking after his father 
physically, the latter being a tall and powerful man. Like other men 

♦An Address delivered before the Faculty and Students of the Medical Department 
of the University of Michigan, on "Founders' Day," February 22, 1906. 



50 ORIGINAL ARTICLED. 

who have achieved eminence, as a child Doctor Gunn showed some of 
those traits of character which explain in a great measure his success, 
especially his love of mechanics, and a distinctly quick and logical miad 
that swne anecdotes which I shall relate will prove. 

The family homestead being located on the main stage route from 
Rochester to Canandaigua was so conveniently situated that, encouraged 
by the reputation the Gunns had for hospitality, travelers often stopped 
there, and clergymen and other men of education made short stays with 
them. Doubtless, the wits of the young Moses were sharpened and 
stimulated by frequently listening to the conversation of educated and 
cultured men, this in some measure accounting for his nimbly-acting 
mind. One day, when only a little fellow, he was tinkering at a home- 
made vehicle, and a brother teasingly asked him why he did not hitch 
up the old dog and make him pull the wagon. Moses replied that he 
was too old. The brother reto rted *'I am going to kill this dog, for he 
is too old and useless, and'-^^^t^ ujilgo^tw^h room," when instantly 
Moses flashed back, "iMg^are going to Kill^exery thing that is too old, 
you had better go in amlp kill your grandmotK 

Again, dissatisfiecft witWDfiiT 8^€l9ft7^skedi why he had been so 
called, and being told B^^is mother that it wWthe name of his grand- 
father, who was a courte8^g/g^mjsybl« p}<^j;gatieman, whom his parents 
hoped to have him emulate, hetlUiLRljf aiTswered, "that is a good reason 
but I could just as well have emulated him without his name." When 
barely five, one Thanksgiving day he was overlooked when some deli- 
cacy was handed around. Turning to his aunt he reproachfully said, 
"Whatevr that uhis you didn't pass it to me/' At once the dish was 
handed him when with sly humor he said, "Oh, never mind, I do not 
twint it, only I like to have folks pass me things when I am around." 

Like straws which prove which way the wind blows, these anecdotes 
show that the quickness of perception, power of logical deduction, and 
sense of humor which characterized his after life, even at this early age, 
were unusually developed. 

I would especially ask for the attention of the undergraduate stu- 
dents to the brief remarks I shall make concerning Doctor Gunn's boy- 
hood. Although for a time, as will be seen, seriously handicapped by 
ill-health, enjoying no special advantages over his fellows, yet, availing 
himself of every opportunity, however unpromising it appeared, he 
actually converted what would have been obstacles to others, into oppor- 
tunities for planting his feet on the lowest rungs of the ladder of 
success. As Longfellow says: 

"All common things, each day's events. 
That with the hour begin and end. 
Our pleasures and our discontents, 
Are rounds by which we may ascend. 

We have not wings, we cannot soar; 

But we have feet to scale and climb 
By slow degrees, by more and more, 

The cloudy summits of our time." 



LIFE OF MOSES GUNN. 51 

Sent early to school, from twelve to fifteen years of age he had for 
his tutor a young theological student, a resident in his father's house. 
Finally, entering the Bloomfield Academy he continued his studies 
there until attacked by a serious illness, his behavior during which 
showing how his strong will could compel his suffering body at any 
cost to obey that which approved itself to him as right. Thus, during 
part of this illness he rode to school, at times suffering so much that 
he could only permit his horse to walk, while the pain in his side made 
it almost impossible for him to sit upright in the saddle, but, recog- 
nizing the evils of such an attitude in the young, he sternly resisted the 
inclination. 

Undismayed by his illness he displayed much fortitude. Instead of 
succitmbing and abandoning the hope of completing his education, he 
accomplished what he could and devoted himself to the recovery of his 
health. The execution of this project requiring extreme care for two 
years and finally a change of residence and a sea voyage, shows the 
mental fibre possessed by this youth, and the discipline of patience 
required must have served to mould his character with finer lines and 
into more compact form. 

A few months after his return from his voyage he commenced the 
study of medicine under Doctor Edson Carr, of Canandaigua. That 
the same keenness of observation, and accurate correlation of the facts 
thus obtained were as prominent traits of character during his student 
days as they had been in his childhood is proved by a remark of Doctor 
Carr evidencing the opinion this shrewd observer had early formed of 
Gunn. Walking side by side one day, the wind blew a corner of the 
doctor's cloak over Gunn's arm, when the pupil remarked, "How proud 
I should be if your mantle could fall upon my shoulders." Gazing 
keenly at him for a moment Doctor Carr replied, "My boy, you will 
wear a greater mantle than mine." Doctor Carr enjoyed a high repu- 
tation as an operator and was greatly admired by his pupil, yet on one 
occasion after assisting his preceptor in the performance of an 
operation, Gunn remarked to a friend that if he ever met with a similar 
case he would treat it after a radically different method. Years after, 
in a number t>f instances, the truth of his youthful previsions was jus- 
tified by his results. Such independence of judgment coupled with a 
well-balanced mind such as Gunn possessed, was one of the chief 
reasons for his early success ; when sure he was right, he did not hesi- 
tate to contravene professional conventions. 

A former student of Doctor Carr's, our own Corydon L. Ford, then 
Demonstrator of Anatomy in Geneva Medical College, on his occasional 
visits to his old preceptor was struck by Gunn's "earnestness in what- 
ever he undertook," and especially "his enthusiastic devotion to the 
study of anatomy." Upon the observations thus casually made by Ford 
depended the after life of young Gunn. I am anxious in thus selecting 
from the mass of material at my disposal the really epoch-making 
events of Doctor Gunn's life, that students may recognize how at an/ 
period of life a man as he really is, not as he wishes to appear, is often 



62 ORIGINAL ARTICLES. 

subjected to an unsuspected scrutiny upon the results of which, all 
unknowingly to himself, his future in great measure may depend. 

In October, 1844, entering the Geneva Medical College, Gunn was 
at once conceded to be a man of unusual promise, and Dr. Ford's 
originally high opinion was so justified that, when the latter's health 
prevented him from conducting his work in practical anatomy, he 
entrusted to the young undergraduate the instruction of his classmates, 
thus giving the opportunity Gunn needed. Ford afterwards ^aid that 
Gunn in performance of these duties evinced so much aptness and skill 
in instructing others, that his future success as a teacher and operator 
were clearly foreshadowed. Even at this time young Gunn, encouraged 
by Ford, and given a chance to show his capacity as a teacher, when 
talking over the future, indulged the hope that he and Ford might at 
no distant time be associated in a medical school, Ford as the Anatomist, 
Gunn as the Surgeon. To paraphrase the Shakespearean saying, the 
wish became the father to the thought, and the thought induced Gunn 
to bend all his energies to translate his thought into a reality. 

The quickness with which Gunn availed himself of an opportunity, 
which most would have failed to make adequate use of, is shown by 
a circumstance which occurred just before his graduation. The college 
received, too late to utilize for the session, an unclaimed body for dis- 
section. There being no means for preserving it Doctor Gunn was 
allowed to use the body for purposes of instruction. He packed the 
body in a large trunk, and receiving his diploma on Tuesday, left his 
home for Ann Arbor on the Monday following the day of his gradua- 
tion. Two weeks after leaving home he made his arrangements and 
commenced lecturing on anatomy, which proved so successful, that in 
succeeding years he repeated this course accompanied by dissections 
and demonstrations. This was the first course on anatomy ever given 
in Ann Arbor, and probably the first in Michigan. I am credibly 
informed that these lectures and demonstrations were given in the 
basement of the old court house which occupied the site of the present 
building. 

In July, 1849, Doctor Gunn was appointed to the chair of Anatomy 
in the University of Michigan to which was added the Professorship 
of Surgery early in 1850. In 1854 it was deemed advisable that Doctor 
Gunn should teach only Surgery, and in June of this year Doctor 
Corydon L. Ford was appointed to fill the chair of Anatomy. Thus 
at last the youthful dreams of these two enthusiastic men were realized, 
one taught Anatomy and the other Surgery in the same medical school. 
The year previous to his appointment by the Board of Regents — 1848 — 
Doctor Gunn married Jane Augusta Terry, only daughter of J. M. 
Terry, M. D. The fruits of this union were four children, the eldest 
of whom, Glyndon, was accidentally drowned in the Detroit river in 
the summer of 1866. The remaining three children survived their 
father. 

In 1853 he changed his place of residence from Ann Arbor to 
Detroit, where he remained until called, in 1867, to Rush Medical Col- 



LIFE OF MOSES GUNN. 63 

lege. From 1853 to 1867 he made two weekly trips to Ann Arbor, 
during each session, to deliver his lectures on Surgery. Recognizing 
that he should pattern his teaching after the best models he determined 
to spend the winter of 1849 and 1850 in visiting the medical schools 
and hospitals of New York, Philadelphia, and Boston, before delivering 
his first course of lectures at Ann Arbor to the entering class consisting 
of ninty-two students. I cannot refrain from quoting some of Doctor 
Gunn's keen observations upon the difference in the mediqal atmos- 
pheres respectively of Philadelphia and New York. He justly con- 
sidered that Philadelphia then was, from the medical standpoint, the 
Paris of America, and while this visit preceded my student days some 
twenty-six years, in my time this was equally true. "There is a medical 
atmosphere which is really refreshing," says he in a letter to his wife. 
"You see the M. D.'s in this City of Brotherly Love have a kind of. 
hospitality peculiarly their own." This remark was evoked by the 
hospitality that men who had won great names in medicine accorded 
this young aspirant for fame, such men as Charles D. Meigs, Joseph 
Pancoast, John Neill, Professor? Mutter and Homer, all insisting upon 
his accepting numerous social invitations and making him free of their 
homes, merely because he was a member of the same profession. 
Doctor Gunn then goes on to say in this same letter, "The New Yorkers 
have a good deal of suavity, but the politeness of the Philadelphia 
doctors is extended in the way of generous hospitality, and almost 
every member of the profession that I have met seems to be imbuecf 
with the same disposition. As I said before, Philadelphia contains a 
medical atmosphere that is most refreshing, and if you could see the 
way the doctors do it up here, you would admire the profession more 
than you now do." 

Urged by patriotic and humanitarian motives, and recognizing the 
fact that, in modern parlance, the battlefield was one of the surgeon's 
laboratories, he joined the Army of the Potomac on September i, 1861, 
as Surgeon to the Fifth Michigan Infantry, remaining in the^service 
until failing health compelled him to resign in July, 1862. Returning 
to Detroit during a three-weeks' leave of absence, in December and 
January, 1861-62, he crowded into this time his quota of lectures at 
Ann Arbor and rejoined at Alexandria. Leaving this place with his 
regiment Doctor Gunn served through the Peninsular Campaign until 
his resignation in July, 1862. 

Like many other men at that time he was an enthusiastic admirer of 
General George B. McClellan, and with generous indignation expressed 
in his letters his opinion of the politicians who, he said, marred the 
General's plans. This was in accordance with his character, for if, 
after what he considered sufficient deliberation, he arrived at an opinion, 
to this he would cling most tenaciously, notwithstanding valid argu- 
ments to the contrary. This trait of character I frequently observed in 
our mutual intercourse. Both as an illustration of his capacity of 
unburdening his mind in well chosen language, as well as to call atten- 
tion by his burning words to the unrewarded heroism of the profession 



64 ORIGINAL ARTICLES. 

you medical students are about to enter upon. I shall quote a portion 
of one other letter. 

"You say that Mrs. R. complains that Surgeons are never alluded 
to after a battle. No; why should they be? Poor, benighted souls; 
did anyone dream for a moment that a surgeon's field had aught of 
glory about it? No; the glory consists of carnage and death. The 
more bloody the battle, the greater the glory. A surgeon may labor 
harder, must labor longer, may exhibit a higher grade of skill, may 
exercise the best feelings of our poor human nature, may bind up many 
a heart as well as limb, but who so poor as to do him honor? There is 
ho glory for our profession. We may brave the pestilence when all 
others flee; we may remain firm at our posts when death is more 
imminent than it ever was on the battlefield ; but who sings our praise ? 
Does the world know who the physicians were who fell at Norfolk 
when yellow fever depopulated that town ? Does it know who rushed 
in to fill their places? And of those who survived can it designate 
one? Did they survive to receive fame? Yet those men were braver 
than the bravest military leader, for theirs was bravery unsupported 
by excitement or by the hope of fame. No ; there are none so poor as 
to do us reverence. And thank God there are few of us so unsophis- 
ticated as to expect it." 

While this is lamentably too true, yet it is the glory of our profes- 
sion that unlike the soldier, striving neither for glory nor for promotion, 
the medical man simply does his duty because it is his duty. 

I cannot refrain from citing an incident in order to impress upon 
the minds of medical students that the welfare of a patient should be 
paramount to every other consideration; Although what I shall relate 
happened upon the battlefield, as has just been pointed out, the same, 
nay a higher kind of courage is often demanded when facing disease, 
as is daily done by the rank and file of the profession. In a skirmish 
against one of the hill tribes on the frontier of India, an officer was 
severely wounded in advance of his troops as dusk was coming on. 
One of the large arteries was wounded and death from hemorrhage 
was imminent. The surgeon of the party ran forward and in com- 
parative shelter compressed with his fingers the artery, arresting the 
bleeding. While the location of the fire of the enemy shifted, it con- 
tinued. Doubting the efficiency with which he was compressing the 
artery, night having now fallen, the surgeon deliberately lit a match 
instantly causing a hail of bullets to fall around him, and then finding 
his patient in great danger of being wounded a second time, arranged 
an efficient makeshift to take the place of his fingers in arresting the 
bleeding, picked up his patient at the greatest risk to his own life, 
carried him to the rear, tied the severed artery, and saved him ! What 
is the rush forward with victorious thousands compared to such an 
act of heroism? I am glad to say that this British surgeon received 
the Victoria Cross for Valor, but who receives any recognition, as Gunn 
says, when deliberately facing death from loathsome disease? 

Although much of interest remains concerning Doctor Gunn*s life 



LIFE OF MOSES GUNN. 55 

at this time which would be instructive and interesting, enough has 
been said to indicate most of his characteristic mental traits, and now 
it behooves us to briefly consider what additional qualities rendered 
him so remarkable as a teacher. Although from the purely intellectual 
standpoint the physique of a teacher should play no part in his success, 
even now\ a stalwart frame, fine voice, an impressive and commanding 
presence, coupled with enthusiasm, will go far towards securing the 
attention and winning the confidence of scholars, after which the mental 
pabulum offered is accepted by them with but little question. 

When Doctor Gunn commenced teaching, in this country an 
instructor had first to be a man whom manly men could admire, mere 
intellectual force alone being decidedly at a disadvantage, having 
slowly to win attention instead of compelling it. Gunn and men of his 
stamp commanded attention and confidence, the students unconsciously 
placing themselves en rapport with an instructor so • bounteously 
endowed physically. The same was true of almost all the great 
teachers of Surgery of Doctor Gunn's generation, such men as the 
elder Gross, Hunter McGuire, David Yandell, Edward H. ^^oore and 
others I could mention. 

1 shall never forget how I was impressed by my first sight of 
Doctor Gunn twenty-three years ago. Sauntering along the street a 
half block away I saw the striking figure of a man considerably over 
six feet in height, well proportioned, with an erect military carriage, 
clad in a snugly-fitting, carefully-buttoned-up black frock coat, his head 
surmounted by a high black silk hat. He had long gray side whiskers, 
a heavy drooping moustache, and curling gray hair resting upon his 
coat collar. He frequently raised his gold-rimmed eyeglasses to note 
the architectural peculiarities of each house he approached, every street 
incident, every passer by, and then the eyeglasses were allowed to 
swing from their long gold chain to be again quickly readjusted should 
anything seem worthy of attention. Altogether he presented an impres- 
sive figure of' a man of physical and mental power, of one who must 
investigate everything presented to his senses, who quickly observed, 
classified his impressions, deciding upon the respective merits and 
proper relation even of passing events, a man of an alert and enthu- 
siastic temperament, ready and eager to digest new ideas, yet one whose 
judgment restrained his zeal within due bounds. The essentials of 
these impressions were instantaneously photographed upon my mental 
retina and I subsequently found them to be accurate. A man thus 
opulently endowed by nature and trained by a life of continuous 
effort to excel, could not fail to command at the very outset the atten- 
tion and confidence of any audience, and to exert an actively compelling 
influence over them. 

The modern student can only have a faint conception of the stress 
laid, forty or fifty years ago, upon the manner, as well as the matter 
of a lecture. At the present time, almost any form of expression is 
permissible that the speaker believes will convey his ideas, so the 
naked truth, or what is too common, truth clad in ill-fitting, actually 



56 ORIGINAL ARTICLES. 

distorting verbal garments, disgusts or fails to impress the hearer, or 
more often, an entirely wrong idea is conceived. Slang, catchwords, 
anything will do? Qear cut thoughts neither will be nor can be 
expressed in crude, slovenly language. A careless, loose mode of 
expression, no effort being made to clothe ideas in appropriate and 
decorous speech, is always an evidence of ill-digested, loose thought; 
nay more, it inevitably leads to less and less effort being made to think 
or observe clearly. 

Gunn and his contemporaries recognized and avoided these pitfalls. 
Careful deliberation was employed in deciding exactly what informa- 
tion was to be given, but an equal effort was put forth in securing 
fitting language to convey with exactness the facts to be considered. 
Let none think that it was pedantic or an unnecessary refinement to 
mentally alter or recast phrases before giving them verbal utterance, 
because this is a necessary part of any good lecturer's work. Gunn 
and his successful contemporaries understood the necessity of so lec- 
turing that the audience did not become dulled by constantly listening 
to nearly the same phraseology employed to convey different ideas, and 
thus lose all the subtler differences in scientific values because of the 
lack of nice discrimination in the language employed by the speaker. 
Happy is he who at the outset possesses a large vocabulary, but he 
must never lose an opportunity to add to his store of words. A lec- 
turer who conscientiously searches out the exact word or phrase to 
correctly convey a given idea will find his mental vision wonderfully 
clarified, and will rarely have to answer questions propounded by his 
mystified class. Let me give you an illustration of the plan pursued 
by another of our great teachers of the past. Doctor Francis Gumey 
Smith, Professor of Physiology in the University of Pennsylvania, when 
I was a student there. Two hours of the evening preceding the lecture 
was spent in consulting authorities and refreshing his mind as to experi- 
ments, et cetera. At i o'clock the next afternoon he went to his room 
at the medical school, read over the stenographic report of this same 
lecture delivered during a previous course, saw that the vivisections 
demonstrated what he desired, or, that the experimental apparatus was 
working properly, and then, the last three-quarters of the hour pre- 
ceding his 5 o'clock lecture were devoted to selecting the most fitting 
language to employ in recapitulating the previous lecture, and for the 
lecture about to be delivered. 

Can you wonder that it was a rare treat to listen to such a speak- 
er's smoothly-flowing sentences, and that we exactly apprehended what 
he strove to teach us? And this expenditure of five or six hours in 
the preparation of each lecture was not only made when Doctor Smith 
commenced teaching, but after twenty-five years of practice. Let no 
one think that it is unnecessary to thus cut, alter, and recast phrases, 
for to such precautions do I attribute much of the successful teaching 
of years ago. 

No experienced lecturer thinks it beneath him to search until he 
finds the exact word or phrase to convey a given idea, even if he has 



LIFE OF MOSES GUNN. 57 

to restate that which he has already presented more obscurely to his 
audience. I firmly believe that if some of the present opponents of 
so-called didactic lectures as a means of conveying scientific knowl- 
edge, could have listened to the really great teachers of the past, much 
of their opposition would be withdrawn. But to attain such skill is 
no easy task, even for those starting with unusual endowments, the 
aspirant for laurels as a speaker cannot indulge in careless, inaccurate 
language in ordinary conversation, or in his correspondence. These 
faults were conspicuously absent in Doctor Gunn. I have read many 
letters of his, portions of some of which you have listened to, and 
the same happy lucidity that illuminates his more pretentious writings 
characterizes his family correspondence. He thought clearly and took 
the trouble to always employ that phraseology which compelled his 
readers or hearers to apprehend him exactly. Doctor Gunn as a lec- 
turer was so clear in his rapid, emphatic statements that he impressed 
his auditors with his thorough mastery of his subject. He was a 
scholarly and accurate speaker, one of the best examples of the old 
method of preparing and delivering didactic lectures. Punctuality in 
the lecture room was one of his articles of religion. His superb figure 
and commanding presence at once centered the attention of the class 
upon him. Doubtless some of his facility as a speaker and writer was 
due to his connection as editor with the Monthly Independent and its 
successor, the Peninsular and Independent Medical Journal, His pub- 
lic clinical work was his chief delight and his reputation was largely 
due to these lectures and his operative skill, his contributioris to lit- 
erature, as we shall see, unfortunately being few indeed. Full of fun 
and anecdote, which he often most skilfully employed to fix in the 
minds of his auditors certain facts he was discussing, he was never 
known to indulge in an unclean joke or allusion, such being utterly 
abhorrent to his nature. If the occasion demanded some mention of 
the errors of another physician, this was done in the kindest, most 
unobtrusive manner. He was absolutely considerate of others in a 
consultation and was never known to speak unkindly, professionally, 
of another physician. He was a most skillful diagnostican, and arrived 
at his conclusions with startling rapidity, so much so that he was 
unjustly accused of being careless. Exactly the reverse was true, but 
his accuracy of observation and the rapidity of his mental processes 
explain the ease and speed of his diagnoses. As a clinician he was 
above everything painstaking. Every step of an operation was care- 
fully traced out; every possible . complication and its remedy forseen 
and provided for; every instrument or appliance was mentally — as it 
was later actually — set aside in its place; everything was accurately 
mapped out. This studious observation of minute details secured the 
remarkable success which crowned his efforts. His frankness in deal- 
ing with patients was conspicuous. He never made disingenious or 
misleading statements, nor would he consent to deceive his patients as 
to their true condition. He was free from any taint of dishonesty with 
patient or practitioner. On one occasion a consultation was being 



58 ORIGINAL ARTICLES. 

held over an obscure case, Doctor Gunn being present. When asked 
his opinion he replied: "Gentlemen, I have practiced surgery long 
enough to learn that it is a wise thing in a doubtful case to be modest 
in expressing an opinion. I do not know what this tumor is and I 
think it had better be let alone." Duty well done, his whole duty to 
his patient, seemed his sole guiding motive. When once asked in a 
note handed to him while lecturing, "What is a doctor's best road to 
success," he replied with great earnestness and solemnity, "Young 
man, your best road to success is to deserve to succeed." 

His judgment as an operator was excellent. He possessed a cool 
head, steady, iron muscles, which yet could wield a scalpel like an 
artist's pencil, and above all, a most minute and accurate knowledge of 
anatomy. With such endowments and that supreme self-confidence 
born of past successes, and full preparedness for any emergency, Gunn 
was a bold, rapid, brilliant, and at the same time neat operator. 
Although the boldest of the bold when occasion arose, as we have seen 
he was in reality most careful of the indispensable details without 
which disaster so often must come. He never ceased to feel the burden 
of responsibility and when operating would permit of no levity of 
manner. As he once said to another physician, "I never can, although 
I often wish I could, divest myself of anxiety and responsibility in 
dangerous, or more especially troublesome cases; they keep me in a 
painful state of concern." His mechanical ability was pronounced; 
as some one said. "His instrumental paraphernalia, straps, and splints 
and bandages, alw^ays fitted the variety of the species, and not merely 
the class and order." 

As a writer Doctor Gunn wielded a facile pen which lacked neither 
force nor point. He employed nice discrimination in the selection of 
words, so that he was a remarkably clear writer, while his style, instead 
of consisting of the short, staccato sentence, which is the only style 
some men can employ to make themselves understood, was a decidedly 
flowing one, pleasant to read, yet most lucid. He possessed to an 
eminent degree that indefinite something we call grace of diction. He 
thought so rapidly and accurately that of necessity he was compelled 
to employ a large number of words, and in perusing his articles the 
reader usually overlooks the exceptionally large vocabulary employed, 
and wonders why he understands so readily sentences that sometimes 
contain over fifty words. His thorough reading and speaking knowl- 
edge of German, and an excellent acquaintance with French, added to 
the range of his literary acquisitions, hence the appropriateness of his 
illustrations and citations, when rapidly pouring forth a flood of 
language, was remarkable. 

It is much to be regretted that the great Chicago fire destroyed the 
manuscript of a work on Surgery which Doctor Gunn had nearly 
completed. Upon the Programs you will find the titles of the papers 
and addresses which, with numerous editorials published in the journals 
of which he was editor, and discussions of the papers of others read 
before the American Surgical Association, comprise all the literary 



LIFE OF MOSES GUNN. 59 

remains bequeathed to us by Doctor Gunn. Of their value none can 
doubt, and especially those upon the "Philosophy of Certain Disloca- 
tions of the Hip and Shoulder, and their Reduction." As Doctor Senn 
remarked, "He left us no encyclopedia of medicine but his little 
pamphlet of less than twenty-five pages contains more than many 
others have compiled in bulkier form." 

During the winters of 185 1-2-3 Doctor Gunn made numerous dis- 
sections which proved that the untorn portions of the capsule in dis- 
locations of the shoulder and hip were the cause of the characteristic 
attitudes assumed by the limbs, and furthermore were the true obstacles 
to reduction. He further demonstrated that the return of the dis- 
located bone to its socket "can be easily effected by putting the limb 
in such a position as will effectually approximate the two points of 
attachment of that portion of the ligament which remains." Doctor 
William H. Reid, of Rochester, New York, on May 8^ 1850, had 
described a method of reduction by manipulation which was essentially 
one procedure which is yet employed, but he failed to point out cor- 
rectly the obstacles to be overcome and the mechanism of the reduction. 
Doctor H. J. Bigelow, of Boston, was doubtless familiar with Reid'? 
method which had been published, in connection with a controversy 
excited by Reid's original paper, in the Boston Journal about 1851-2. 
Doctor Bigelow continued to reduce dislocations on the cadaver before 
the medical class by a method of manipulation from 1854 until 1861, 
believing with Reid that the muscles caused the fixed attitude of the 
limb, et cetera. Then, as Doctor Bigelow says, "In the spring of 1861, 
having been lead to expose a joint, the luxation of which had been 
the subject of a lecture, I was agreeably surprised to observe the sim- 
ple action of the ligament, — a simplicity which subsequent experience 
has confirmed, and which strikingly explains the phenomena observed 
in the living subject." Had Doctor Bigelow deigned to cast his eyes 
over the Peninsular Journal of Medicine, Ann Arbor. 1853-4, Volume 
I, pages 95-100, he could have learned all the facts that he needed to 
know, which had been deliberately sought for and discovered by the 
obscure young western surgeon, not accidentally seen, as Doctor 
Bigelow states was the fact with regard to his own discovery. 

There can be no question that to Gunn belongs the priority of dis- 
covery as to the causes of the characteristic attitude of limbs dislocated 
at the shoulder- and hip-joints, what the obstacles to reduction are, and 
the simple principle of relaxing these unyielding structures by position 
and inducing, without force, the bone to retract the course it pursued 
when escaping from the stocket. Although everything that Gunn 
wrote was of distinct value, his reputation as an investigator and 
original writer must depend upon this admirable piece of work. 

In 1856 Geneva College conferred on him the Honorary degree of 
M. A., and Chicago University that of LL. D. in 1877. At the time of 
his death Doctor Gunn was an active member of the American Surgical 
Association, of the American Association of Genito-Urinary Sur- 
geons, of the Illinois State Medical Society, of the American Medical 



60 ORIGINAL ARTICLES. 

Association, of the Chicago Medical Society, and had been a member 
of several of the Congresses of American Physicians and Surgeons. 
He served as surgeon on the active and consulting staffs of a number 
of charitable institutions, notably the Cook County Hospital, Saint 
Joseph's Hospital, Saint Luke's Hospital, and especially the Presbyterian 
Hospital, intimately connected as this was with the Rush Medical Col- 
lege, where he held the Chair of Surgery for nearly twenty full years. 

On the fourth of November, 1887, after an illness of some weeks, 
this noble physician passed beyond the veil to his well-earned reward. 
He was a lifelong, consistent and faithful member of the Episcopal 
church, belonging to the old-fashioned high church school. Despite 
the materialism of many of his fellow-doctors, he said, "I often doubt 
terribly, but I say to myself, I looked this thing all over once, I went 
through the arguments and I decided that the immense balance of 
testimony was in favor of Christianity, and I cannot take time to go all 
over it again." 

Doctor Gunn's tenderness to his child patients and their love in 
return for him was very striking. His fondness for animals, flowers 
and natural beauty was strongly developed and freely indulged. Unlike 
too many physicians, he did not permit his profession to absorb and 
narrow him, if for no other reason, lest his powers as a practitioner 
and teacher should be crippled thereby. In addition to the study of 
foreign languages and the literature of our own tongue, Doctor Gunn 
was at one time a most enthusiastic and well-informed astronomer, 
thus providing himself with a resource which, when drawn upon, could 
bear him away irom his daily worries, rest his mind, and serve to 
elevate his thoughts from material to spiritual things. Well would it 
be if every one of us would strive for ^me form of knowledge and 
culture alien to that of our profession. Doctor Gunn was fond of and 
shone in society as a conversationalist, now one of the nearly lost 
arts. 

I have apparently striven thus far to present you an idealized 
picture of a flawless man, which none of us believes to exist. It 
remains for me in my peroration to point out some of the glaring 
defects inseparable from a character such as I have endeavored to 
depict. He was imbued rather too strongly with a sense of self-respect, 
allied to, but something far nobler, than conceit. Conceiving the idea 
that he was born to govern in many things he sometimes aspired to 
command outside of his legitimate sphere. He was intolerant of argu- 
ment on almost any subject, and often did scant justice to his opponents. 
He could be bitingly sarcastic, and resort to ridicule, which, as I once 
told him, was not argument, and totally out of place in a scientific 
discussion. He was prompt and sharp in his dealings with the blunders 
and shortcomings of anyone who failed to do what he considered was 
their best. In some things he was radical to the point of being revo- 
lutionary. He never catered for popularity by shading his expressions 
of opinion, but struck as l^ard as it suited him, without regard for 
consequences. In his determination to be absolutely honest in the 



LIFE OF MOSES GUNN. 61 

expression of his opinions he sometimes appeared harsh, when he was 
really actuated by the best motives. While tenacious of professional 
opinion, he never claimed to be able invariably to correctly diagnose 
the innumerable conditions presented for his consideration, often 
quoting to the students, the saying, "if your foresight was as good as 

your hindsight you would not make so many mistakes by a 

sight." He was an ideal consultant, never by word or action criticizing 
the attendant before the patient ; if he had anything uncomplimentary 
to say, it was said to the physician, as it always should be, in private. 

To sum up, then, Gunn was a notable and noble figure of a man, 
one of whom the profession and especially this school has good reason 
to be proud. An honest, high-toned, unselfish, Christian gentleman; 
a hater of shams in any form; a good son, husband and father; an 
example of devotion to the noblest of professions, and through it a 
benefactor of humanity ; our most illustrious Founder, one whom every 
student present should strive to emulate. 

And now, shade of a most gallant and knightly physician, whose 
shield was so often successfully interposed between his intended victims 
and the Grim Destroyer — Death, farewell. May the example of your 
life shine as a beacon light to lead us on to nobler endeavor, and may 
the voice of your teachings long continue to "echo through the cor- 
ridors of Time." 

I append the following list of his writings : 

"Philosophy of Certain Dislocations of the Hip and Shoulder, and their 
Reduction." Peninsular Journal of Medicine, Ann Arbor, 1853-4, Volume I, 
pages 95-IOO- 

Reprinted with some additions in the same journal 1855-6, Volume III, 

pages 27-35. 
Reprinted in pamphlet form, 1855. 
Reprinted with further additions in the Peninsular and Independent 

Medical Joumctl, 1859-60, Volume II, pages 193-206. 
Reprinted in pamphlet form 1859. 
Second edition printed in 1869. 
"Selections from Surgical Notes." Medical Independent, Detroit, 1857-8, 
Volume III, pages 67, 186, 257, 377, 469, 575- 

"Selections from Surgical Notes." Peninsular and Independent Medical 
Journal, Detroit, 1858-9, Volume I, pages 464-467; 1859-60, Volume II, pages 
140-143. 

Doctor Gunn was one of the ^editors of the Monthly Independent, Detroit, 
1857-8, Volume III, and of the Peninsular and Independent Medical Journal, 
1858-9, Volume I; and 1859-60, Volume II; and was the author of numerous 
editorials in these journals, usually signed "G." 

"Address of Welcome to Rush Medical College," delivered October i, 1867, 
Chicago Medical Journal, 1867, Volume XXIV, pages 499-512. 

"Valedictory Address, Rush Medical College," 1870-71. Ibid., 1871, Volume 
XXVIII, pages 157-169; also reprinted. 

"Surgical Clinic of Rush Medical College." Ibid.. 1874, Volume XXI. 
pages 560, 725. 

"Discussion of Doctor Gross' Paper on Syphilis." "Transactions American 
Medical Association," Philadelphia, 1874. Volume XXV, page 243. 



62 ORIGINAL ARTICLES. 

"Case of Traumatic Tetanus, Saint Joseph's Hospital." Chicago Medical 
Journal and Examiner, 1875, Volume XXXII, pages 421-426. 

"Address in Surgery and Anatomy," delivered May 8, 1879. "Transactions 
American Medical Association," Philadelphia, 1879, Volume XXX, pages 

79-493. 

"Report of a Case of Purulent Effusion into Knee-joint." Ibid., 1879, Vol- 
ume XXX, page 517- 

"Treatment of Fractures of the Skull, Recent and Chronic, with Depres- 
sion." Read June i, 1882. "Transactions of the American Surgical Associa- 
tion," 1881-83. Philadelphia, 1883, Volume I, pages 83-90. 

"The Doctorate Address on Medical Ethics." Chicago Medical Journal and 
Examiner, 1883, Volume XLVI, pages 337-352. Also reprinted. 

"The Philosophy of Manipulation in the Reduction of the Hip and Shoulder 
Dislocations." "Transactions American Surgical Association," (1884) 1885, 
Volume II, pages 399-519; also in Chicago Medical Journal and Examiner, 1874, 
Volume XLVI II, pages 449-468. Also reprinted. 

"The Union of Nerves of Different Function Considered in its Pathological 
and Surgical Relations." Address of the President delivered April 28, 1886, 
Volume IV, pages 1-13. 



BORDERLAND CASES OF INSANITY.* 
By IRWIN li. NEFF, M. D.. Pontiac, Michigan. 

ASSISTANT PHYSICIAN AT THB KASTBBN MICHIGAN ASYLUM POR THB INSANB. 

The subject which I have chosen is not an uninteresting one. 
Many cases of questionable insanity have been reported and valuable 
information has been obtained. A reference to the literature on this 
subject will show a voluminous bibliography. My intention is not to 
particularize, but to correlate some of our knowledge on this subject 
and isolate a few of its practical aj>plications, — facts which would 
appeal to the interest of the general practitioner. 

Borderland cases, correctly speaking, would comprise all those cases 
in which the alleged irresponsibility of the individual is unproven. As 
is well known such a definition would include a number of conditions, 
and it is true that many and diverse symptoms accompany such a case. 
It is obvious that one considering a "borderland case" must be con- 
versant with both normal and abnormal psychology. As it is admitted 
that the origin of the moral sense has no fixed period, we see that 
a priori we have a task of no little importance. 

I would also call attention to the fact that we are in danger of going 
to the extreme. On one hand we have the ruling of the criminologists 
and students of sociology ; and again we are confronted with the state- 
ment of the extremist, who declares that since the degree of respon- 
sibility cannot always be defined, everyone should have an equal chance, 
and that consequently we should show leniency when occasion demands. 
Many attempts have been made to prove or disapprove these statements, 
but it must be acknowledged that we have reached no conclusioo which 
can give satisfaction. 

*Kead at the Ann Arbor meetins^ of the First Councilor District Medical 
Society, December 22, 1905. 



BORDERLAND CASES OF INSANITY. 63 

For a settlement of this perplexing question we naturally turn to the 
alienists and criminologists. Let us see what they have to contribute. 

Our conception of insanity today is vastly different from our idea 
of the psychosis twenty-five years ago, and this is, in great part, owing 
to our improved clinical interpretation of mental disorders. Much of 
the mystery surrounding practical psychiatry has vanished, ,we hope 
forever. A careful study of a number of cases has shown that a 
grouping of cases is possible, thereby making the nomenclature of 
insanity possible, and simplifying! it to a remarkable degree. We have 
also more correct and definite explanatory terms, and have brought 
closer together the relationship of the neurosis to the psychosis. And, 
lastly, I would call attention to the relationship of bodily conditions and 
mental disturbances. Although we believe that in insanity the essential 
condition is a disordered action of the brain, we admit that the causes 
producing such a disruption may be dependent upon bodily disease or 
defect. It is not strange, considering these revelations, that the psy- 
chiatrists should demand a more careful study of these cases. They 
believe that a more painstaking inquiry into each individual case, along 
certain definite lines, would be of material assistance in clearing up 
the vexed question of "responsibility." 

A review of the writings of alienists on the vexed question of 
"responsibility" will show that there is quite a uniform opinion on the 
question of its restriction. According to a number of prominent 
alienists diminished responsibility is to be charged in cases of even 
slight mental affections, in incipient stages of others (as in that of 
general j>aralysis), in some psychic degenerations, without delirium, 
in borderland cases of insanity, cases of sexual perversion, chronic 
alcoholism, neurasthenia, the general epilepsies, and in certain cases 
of the other neuroses. 

Mercier claims that there is a certain sphere of activity, in which 
every insane individual is to be held irresponsible, but outside of which, 
any act of his may be punishable by law, so that but a few insane can 
be held entirely irresponsible. Mercier inclines to the idea that the 
physician should not be permitted, as such, to decide on the degree of 
responsibility in these cases, but should simply and clearly describe 
the patient's mental state, leaving to the judge the application of the 
law (Journal of Nervous and Mental Disease, Volume XXIX, page 

739). 

The criminologist, proceeding in much the same way a§ the alienist, 
has discovered truths which have proven to be of practical importance. 
As is well known the relation of crime to insanity has been the nucleus 
on which has been built our present knowledge of the criminal. It 
has been definitely decided that there is a true relation, — a relation, 
which like insanity in some of its respects, is difficult to analyze. 

In order to emphasize these statements, and wishing to show con- 
certed opinion in regard to the responsibility of the criminal, I give 
the following quotation : Doctor W. B. Noyes, writing on the "Crim- 



64 ORIGINAL ARTICLES. 

inal Equivalent of Insanity," says that "the importance of fixed idea or 
obsession on obscure cases in crime cannot be too frequently brought 
to the attention of jurists, and the presence of minor eccentricities is 
also important, for there is no sharp line to be drawn between the 
eccentric and criminal action." Such mental eccentricities, Noyes 
believes, are often as clearly stigmata of degeneration as the more 
definitely understood physical stigmata. He also speaks of the crim- 
inal, who knows both concrete and abstract, but lacks what he calls 
"hidden or ethical feeling." "Such a man knows right and wrong, 
but will not, on that account, be kept from committing wrong." 

The practical application of these facts is possible, but united and 
uniform action is called for. It is obvious that there can be no fixed 
rule in "borderland cases," but it is nevertheless true that our judg- 
ment is called for, and our opinion must be rendered. It is true that 
our medical opinions, which should be respected, are often overruled ; 
but we should never hesitate to give our verdict, even to the extent of 
frankly acknowledging our inability to render more than a conservative 
opinion. 

The necessity for expert testimony in these borderland cases is 
apparent. It i^ unquestionable that medical expert testimony would 
be less severely condemned if only the physician familiar with mental 
trouble would consent to testify. An alleged case of insanity cannot 
be hastily decided upon, for the diagnosis should not be placed on the 
existence of a delusion or the presence of some peculiarity, alone. The 
diagnosis of mental disease should rather be dependent on the sum of 
bodily and mental defects, and the proper correlation of facts gained 
by a thorough study of the patient. 

Naturally the determination of insanity in a "borderland case" 
requires the most exquisite care. The case must be most carefully 
considered and extended examinations are often demanded. When 
summoned to examine such a case the physician must remember the 
character of insanity and appreciate the difficulties which he will 
encountei-. The psychiatrist knows that the case requires a most care- 
ful handling, and that he, in all probability, will be met with opposition, 
which, if he is not experienced, may affect his final decision. One 
should also bear in mind that although the practical grouping of the 
insanities is now possible, cases are found which cannot be relegated 
to any one particular gjoup. Nevertheless such cases are cases of 
insanity. The physician should not hesitate to so declare it, giving his 
specific reasons and acknowledging his inability to classify it. It must 
also not be forgotten that insanity is a protean disease, and it may be 
that the peculiarity exhibited by the patient is a prodromal or primary 
symptom of a well recognized form of insanity. We should never 
arrive hastily at our conclusion, and one must remember that when 
undertaking such a case he has set for himself a task which will require 
both tact and perseverance. 

(i) Insanity is a protean disease. Its syndrome is subject to 
variation, and a grouping is not possible in all cases. 



CLINICAL SOCIETY. 66 

CONCLUSIONS 

(2) Borderland cases of insanity are at times more apparent than 
real. A consideration of such cases may show that the obscure s)rmp- 
tom is really an early manifestation of a psychosis, which can be classi- 
fied. 

(3) Medical men when testifying in "borderland cases" should 
invariably give their reasons for their opinion, and should not, if there 
is not sufficient proof, attempt to isolate the symptom and refer it to a 
named psychosis. 

(4) The degree of responsibility in some of these cases, considering 
our present knowledge, cannot be accurately determined. Every case 
is a study in itself, and must be determined on its merits. 

(5) Expert testimony should be given only by experts. If this 
rule was strictly adhered to medical expert testimony would be better 
appreciated. 

(6) Inability to pass upon a case should be frankly acknowledged. 
In cases of doubt, we are justified in giving our testimony, and leaving 
the real decision of responsibility to the court and its representatives. 



TRANSACTIONS. 



CLINICAL SOCIETY OF THE UNIVERSITY OF MICHIGAN. 



STATED MEETING, DECEMBER 15, 1905. 

The President, ROGER S. MORRIS, M. D., in the Chair. 
Reported by DAVID M. KANE, M. D., Secretary. 

REPORTS OF CASES. 
CARDIAC ANEURYSM, 

Doctor George Dock : I wish to describe a case of cardiac aneur- 
ysm. The patient was a farmer of fifty-two years, of intemperate hab- 
its, and with a scar suggestive of syphilis but denial of history of 
infection. From the age of eighteen the patient complained of neuralgic 
pain in the pit of the stomach and of pain and tenderness in the heart 
region. Two years before death he had a slight paralysis of the right 
side, lasting only three hours. For the last four months of life pain in 
the heart region was more severe, paroxysmal, and sometimes radiating 
down the left arm. Unlike most patients with angina pectoris, the man 
became almost maniacal, running around the room, screaming, declar- 
ing that the pain would kill him, but without having the oft-described 
feeling of impending death. For the last two months the pain in the 
heart was almost continuous. There was dyspnea; edema coming on 
first in the lower extremities, then becoming general. Physical exam- 
ination showed all the evidences of incompensation, the heart dilated 



66 ORIGINAL ARTICLES. 

and hypertrophied, with a blowing systolic murmur at the apex. The 
second aortic was accentuated; the radial arteries tortuous, thick, 
slightly uneven; the liver reached to the navel line; urine — specific 
gravity 1015, one-fourth bulk albumin, few hyaline casts. For several 
weeks he had not been able to sleep. Under the influence of morphine, 
diuretin and salt-free diet the patient improved markedly, so that by 
the second day of treatment he was able to sleep lying down. In four 
days the edema was gone and the heart became smaller. Eight days 
after beginning treatment, against positive orders to the contrary and 
with a prediction of sudden death in the event, he ate a large meal, 
started out for a walk, but after going a block, fell over and was found 
to be dead. Autopsy showed adhesions over the front part of the left 
ventricle ; the heart enlarged, containing an aneurysm at the end of the 
left ventricle, and in the septum, containing a thrombus partly old and 
partly recent. There was relative insufficiency of the mitral valve, 
slight thickening of aortic flaps, coronary sclerosis, with obliteration of 
the anterior coronary in the lower part. The other organs showed con- 
gestion, slight atrophy, with moderate parenchymatous and interstitial 
changes. 

Doctor Dock gave a critical summing-up of the case with reference 
to symptomatology, diagnosis, prognosis and treatment. He also called 
attention to some of the points of interest in connection with the subject 
of sudden death, and gave a detailed account of the history of cardiac 
aneurysm from the time of Lancisi. His remarks were illustrated by 
a number of old and modem works on heart disease, including Cor- 
visart, Laennec, Cruveilhier, Carswell, and also some of the more 
important articles in medical periodicals illustrating the development of 
our knowledge of cardiac aneurysm. 

OVARIAN CYST WITH TWISTED PEDICLE. 

Doctor Christopher G. Parnall: Gynecological case number 
1408 was admitted to the University Hospital on September 21, 1905. 
Age forty-two ; married nineteen years. 

Family History. — Negative. 

Personal History. — Had all the ordinary diseases of childhood with 
good recoveries. For many years she has had attacks of headache. 
Patient says she has never been real well. 

Menstrual History. — Menses appeared at age of twelve. Last period 
seven weeks before admission. Very irregular, one to two months. 
Duration, one to two days. Amount scanty, one or two napkins for 
whole epoch. No pain. Moderate vaginal discharge. 

Marital History. — No children. No history of abdrtions. 

Present Trouble. — It began about three years ago with pain in both 
groins, worse on left side. The abdomen increased in size very slowly. 
The enlargement seemed to be general and not confined, even at first, 
to either side. At the last menstrual period there was severe pain in 
the lower abdomen beginning on the right side and extending to the 



CLINICAL SOCIETY 67 

left There is a history of a number of attacks similar to the above 
except that the pain was not so severe. No nausea nor vomiting. 
Patient does not think she had ferer. 

Examination, — There is a great development of adipose tissue, 
patient weighing two hundred and thirty pounds. Otherwise the gen- 
eral examination is negative. There is a marked abdominal enlarge- 
ment extending from the pubes upwards to the epigastrium. This 
swelling is dome-shaped. Lineae albicantes marked. There is a deep 
suprapubic transverse furrow, above which the tumor is dome-shaped, 
smooth and symmetrical. It is sensitive and somewhat movable. Per- 
cussion note is dull over the tumor, tympanitic in the flanks. No fluid 
wave. Vaginal examination shows the uterus retroverted. Append- 
ages not palpable. Nothing can be made out in the fomices of the 
vagina. 

On the day after admission the examination of the urine revealed 
a positive test for sugar. On a so-called carbohydrate-free diet the 
sugar disappeared. The patient was kept on diabetic diet for a week 
preceding operation, during which time there was no reappearance of 
the glycosuria. 

Diagnosis. — Ovarian cyst. On account of the sensitiveness and 
history of sudden attacks of pain, it was thought probable that a twist 
of the pedicle would be found, possibly with adhesions of the cyst wall 
to the surrounding peritoneum, and infection of the contents. 

Operation. — On September 25, 1905, by Doctor Peterson. The 
abdcHnen was opened by an incision thirteen centimeters long, in the 
median line. The subcutaneous fat was six and one-half centimeters 
in thickness. On opening the peritoneum it was found that the cyst 
wall was adherent to it for a radius of about ten centimeters. The 
adhesions were thin and vascular. They were loosened by sweeping 
the hand between the cyst wall and the peritoneum. About nine liters 
of muddy-colored fluid were removed by the trocar. The cyst was then 
easily removed by clamping the pedicle, which was twisted counter- 
clockwise for half a turn. The left ovary was enlarged and cystic and 
was removed. The uterus was held forward by ventro-suspension. 
Four days after operation sugar again was found in the urine and did 
not entirely disappear under diabetic diet. The wound healed satis- 
factorily and convalescence was uninterrupted. 

This case is of interest from the standpoint of diagnosis. Twist 
of the pedicle of an ovarian cyst is not uncommon, still the condition 
often goes unrecognized. 

The torsion may be acute, resulting in severe sudden symptoms, or 
chronic, with less marked changes. In the first variety there is a 
sudden cutting off of the blood supply, particularly on the venous side, 
and hemorrhage into the cyst. Acute torsion may resemble in many 
ways the rupture of an ectopic gestation sac. There is usually sudden 
severe pain coming on after exertion, movements of the bowels, or 
urination. The patient may faint and present signs of internal hem- 
orrhage. 



68 ORIGINAL ARTICLES. 

In the chronic form the torsion is slow, the circulation in the tumor 
is interfered with only gradually, and adhesions often form between 
the cyst wall and the neighboring V^lvic organs or the parietal peri- 
toneum. The cyst may thus obtain a large share of its blood supply 
through these adhesions. 

The temperature is usually not much elevated, generally ioo° to 
102° Fahrenheit. The pulse in acute torsion is frequently very rapid, 
ranging from 100 to 160 per minute. When there is a marked 
adhesive peritonitis vomiting is a prominent symptom. Intestinal 
obstruction may occur as a result of the inflammatory changes involv- 
ing the cyst and intestines or frcxn pressure of the tumor. Palpation 
in uncomplicated cases of ovarion cyst is accomplished without causing 
even discomfort. In case of adhesions involving the Serous mem- 
branes there is abdominal rigidity and marked sensitiveness. A small 
right-sided adherent cyst may indeed be easily mistaken for appen- 
dicitis or periappendical inflammation. 

A CASE OF ACUTE CHOREA. 

Doctor Theophil Klingmann: All the facts which have been 
gathered by the pathological anatomist and the physiological chemist 
in the study of chorea offer no explanation of the defects that give rise 
to the condition. No constant lesions have been found. Although 
certain organic changes are often associated with the disease, it is not 
infrequent to observe cases that are truly functional and give support 
to the view that chorea is an expression of functional instability of 
those nerve centers which have assigned to them the office of con- 
trolling the motor apparatus. Of the actual nature of this derange- 
ment we know little or nothing; whether the fault is primarily in the 
cortical cells or whether the impulses are secondarily disturbed in 
their course down the motor path. Hereditary influence is discover- 
able in many cases of chorea. A neuropathic heredity has been found 
in one-sixth of the cases. Frequently a double relationship of the dis- 
ease can be traced to acute rheumatism on the one hand and to various 
nervous disorders on the other. 

The case in question, a patient of good general appearance, twenty- 
four years of age, gives evidence of hereditary influence. The father 
of the patient has had rheumatism. We must not, however, lay too 
much stress upon this fact, as rheumatism is so common that it is only 
significant when the family tendency is very strong, or when the sub- 
ject has endured much suffering from the disease. The mother of the 
patient died at the age of thirty-six, of pulmonary tuberculosis. One 
sister died of the same disease at the age of thirty. Another sister 
had chorea for several months at the age of fourteen, but recovered 
completely. The patient's health was good until her eighteenth year, 
when she became somewhat nervous and fretful and complained of 
forgetfulness. She recovered from this condition without treatment, 
however, and was quite as well as ever until the present affection began. 
She experienced her first attack of chorea three years ago, when she 



CLINICAL SOCIETY. 09 

was twenty-two years of age and four months past her third confine- 
ment. Her first pregnancy terminated prematurely at seven months; 
the second four years ago at full term; the third and fourth preg- 
nancies also being at regular time. The nervous condition at first 
manifested itself in severe headaches and marked irritability, which 
was followed by involuntary muscular movement in the face, the tongue, 
and later in the upper and lower extremeties. This continued for about 
two months and ended in complete recovery. One year later she had 
a second attack. This siege was much less severe and lasted but a 
short time. She became pregnant soon after this attack and remained 
well until five months after confinement, when a third, the most severe 
attack, developed. 

The patient came to the University Hospital in November, 1905. 
She had suffered frc«n chorea since August without intermission. 
While her general appearance is fairly good she has lost about thirty 
pounds since the beginning of this attack. There is no apparent cause 
for this loss of weight except continual worry and anxiety together 
with annoyance incident to constant involuntary muscular contractions. 
Her sleep is very much disturbed. There is no disturbance of diges- 
tion. The appetite is good. The patient is not anemic. In fact there 
is no evidence of organic disease in any organ except the heart, and 
the lesion indicated gives the patient no discomfort. There is con- 
siderable muscular weakness present. The spontaneous movements 
and incoordination are most marked in the arms and hands, but the 
face, and, to some extent, the lower extremities, were likewise affected. 
The movements are very irregular as to time as well as in character 
and degree. Sensibility is not disturbed and there is no pain or 
tenderness in any part of the body. The mental state is normal. 
The cardiac symptoms, which are the only evidence of organic disease 
in the case, are of great importance. The frequency of organic disease 
of the heart is less in childhood than in youth. In chorea, developing 
late, as it did in this patient, the cardiac symptoms are usually those 
of organic disease and frequently mitral regurgitation. It is reported 
that in nine out of every ten fatal cases the cardiac valves are diseased. 
Statistics in the various clinics show that distinct organic disease 
either preceding or developing during the course of chorea was found 
in thirty-two per cent of the cases. What part this plays as a causative 
factor cannot, with our present knowledge of the disorder, be ascer- 
tained. The changes which have been found after death afford no 
clear indication that the circulation is primarily deranged. In the 
majority of cases of the common form of chorea the heart lesion gives 
the patient little or no discomfort, even though it persists after the 
involuntary muscular movement has entirely ceased. The same is true 
of other pathologic conditions occurring before or during the course 
of the disease. It seems more likely that one common cause disturbs 
the functions of the various organs of the body, as well as the functions 
of the nerve centers in the brain. This cause may possibly be found 
in some toxin which accumulates in the organism. This is borne out 



70 ORIGINAL ARTICLES. 

by the fact that treatment directed to improve elimination through the 
bowels, kidneys, and skin will relieve the symptoms greatly. Further 
evidence is given by the fact that the conditions with which chorea is so 
frequently associated are caused by autointoxication. We must not 
lose sight of other etiologic factors in the treatment of this disease. 
There is a distinct predisposing influence of much importance. Chorea 
occurs most frequently during later childhood when the functional 
develojMnent of the nerve centers has been effected, but the exercise 
thereof has not yet secured stability of function, leaving them very 
susceptible to outside influences. The normal restlessness of childhood 
manifests the predisposition to chorea. With this predisposition is to 
be associated the important fact that emotion has been frequently the 
exciting cause. In the case under consideration the condition devel- 
oped rather late, but at a time when considerable strain was brought 
to bear upon an unstable nervous system by the responsibility of a child 
and other household duties, not to forget the untoward effects of a 
premature labor. 

When the patient came to the hospital it was markedly evident that 
both nutritk>n and elimination were defective. The first attention, 
therefore, was given to these pathologic states. The patient was put to 
bed and kept at rest. Oiloral hydrate was adijainistered in ten-grain 
doses every three or four hours to the extent of controlling the involun- 
tary muscular movements, and in addition five to ten drops of Fowler's 
solution were given three times a day. At present the patient is ahnost 
well. The choreic movements are slightly noticeable in the hands, but 
otherwise have entirely disappeared. Under this treatment the duration 
of the disorder is usually short and the prc^^osis extremely favorable. 



CLINICAL SOCIETY OF THE NEW YORK POLYCLINIC. 



STATED MEETING, JANUARY 8, 1906. 

The President, JOHN J. MacPHEE, M. D., in the Chair. 
Reported by FREDERICK C. KELLER, M. D., Secretary. 

READING OF PAPERS. 
THE TREATMENT OF SYPHILIS, 

Doctor Andrew R. Robinson read a paper on this subject. He 
referred to the different views held on the subject of the treatment of 
syphilis, and stated that he would endeavor to show that syphilis is a 
serious disease in a considerable percentage of cases, and especially on 
account of the tendency after immunity is reached to fatal parasyphilitic 
affections; that the tendency to these parasyphilides depends as a 
special predisposing factor upon the dyscrasic condition accruing in the 
active contagion stage; that the intoxication producing the dyscrasia 
and leading to immunity often is most severe in the period between the 
recognition of the primary sore and the appearance of lesions upon the 



CLINICAL SOCIETY. 71 

cutaneous surface, and, therefore, that syphilis should be treated actively 
as soon as a positive diagnosis of the disease is made. 

The object of such treatment is to inhibit the life action of the 
organism, so that only a small amount, comparatively, of toxin is pro- 
duced, giving immunity with only a mild dyscrasia, and producing a 
minimum amount of injury to the tissues and consequently a compara- 
tively slight tendency to parasyphilides or even tertiary lesions. He 
maintained, also, that in the acute infectious stage it is a rule that the 
less toxin produced in a given case, the earlier the system acquires the 
condition of immunity ; and in syphilis this is important not only for 
the individual affected, but also from a social standpoint, as the sooner 
immunity is obtained the less danger of contagion to others. 

An example of early immunity is that acquired by a mother in a 
case of parental syphilis, when she is not invaded by the syphilitic 
organisms, but acquires immunity by toxins from the fetus. Under 
these circumstances the amount of toxins passing to the mother must 
be small in quantity and therefore the immune condition is acquired in 
a comparatively short period as compared with the time necessary in 
acquired syphilis. 

Syphilis is a serious disease, not only on account of the liability to 
fatal parasyphilitic affections, as locomotor ataxia, but also on account 
of its destructive action on the progeny of syphilitic parents when pro- 
duced during the active stage of the disease, hence the shorter this 
period exists the fewer syphilitic children are produced. 

If the tertiary parasyphilides depend very greatly or principally 
upon the severity of the dyscrasia, and this condition upon the amount 
of intoxication, that is, the amount of toxins produced, and this upon 
the number and activity of the syphilitic organisms in the system, it 
follows that in this special parasitic affection the treatment of syphilis 
must be based upon the microbes, the toxins produced, and the ground 
of the individual affection. Proper consideration of these three points 
constitutes the fundamental basis for the best treatment of the disease. 

Syphilis is a continuous condition from the time of infection until 
the last microbe is gone ; hence the division of the disease into stages is 
not scientifically correct, although for clinical description it is of some 
value. 

In the period between the appearance of the primary sore and the 
so-called secondary stage, represented by cutaneous lesions, the general 
nutrition of the person is lowered, fever is present in varying degree, 
the red-blood corpuscles are diminished in number, the lymph glands 
throughout the body may be affected, the spleen swollen and tender, 
I liver enlarged and the nervous system injured, as shown by the pres- 

ence of neuralgia, headache, lassitude, pains in the joints, bones, and 
j periosteum, and occasionally by an extensive multiform erythematous 

eruption. This shows that before secondary lesions occur upon the 
skin there may be intoxication of the general system, which leaves its 
impress on the tissues and acts as the main disposing factor in the 



72 ORIGINAL ARTICLES. 

^causation of parasyphilides. If this be true, it follows that treatment 
should be commenced in every case as soon as a positive diagnosis is 
made, and if this is done at a stage before cutaneous lesions appear, 
so much the better for the patient. 

Existing lesions in the secondary stage are treated to lessen danger 
of contagion, remove deformity and save tissue, but surely it is better, 
more philosophical, to prevent the formation of lesions, especially as 
they are hotbeds for toxin formations, than to wait until they are 
formed and damage has occurred. The treatment of syphilis should 
be offensive, not defensive. Keep the disease in as quiescent a state as 
possible by inhibiting the life action of the organism ; prevent contagion 
from lesion formation ; promote the elimination of the toxins as quickly 
and completely as possible, and pay attention to the general nutrition 
of the patient. This constitutes the correct treatment of syphilis accord- 
ing to our present knowledge. 

Mercury is the only agent that acts upon the microbe, hence it 
should be given during the entire microbic stage in such manner as to 
secure the best action. lodid of potassium should be given only as an 
aid to the mercury or as an alternative in later stages and at all times 
when tertiary lesions are present. It is rarely indicated during the first 
six months of the disease, and never during the microbic stage, as the 
only agent. 

Against the parasyphilides one should produce a proper degree of 
alkalinity of the system, advise avoidance of everything that causes 
circulatory disturbances and of things that interfere with tissue metab- 
olism, especially alcohol, local irritating agents, et cetera. 

DISCUSSION. 

Doctor Edward L. Keyes, Jr. : While I agree with all the conclu- 
sions reached by the author, I disagree wholly with all the premises. 
Briefly, in his opinion, the way to treat syphilis is as a disease and not 
as an array of symptoms. The most practical method is to settle in 
one's mind the amount of medicine considered necessary in all cases to 
overcome the disease. One grain of iodide of mercury every day for 
three years will conquer it, and even though the skin lesions have disap- 
peared, together with the mucous patches in the throat and all other 
outward manifestations, the physician should still try to live up to his 
ideal of the amount of mercury or iodid that should be taken by the 
patient, whether he stands it well or not. I disagree absolutely with the 
speaker regarding the method of treatment at the beginning of syphilis. 
It is extremely dangerous to proclaim that syphilis should be treated 
before the appearance of a cutaneous lesion, because, in a very fair pro- 
portion of cases, one is unable to make a positive diagnosis until the 
appearance of the secondary lesions. Theoretically, if it is proved that 
the existence of the spirocheta pallida is conclusive of syphilis, treat- 
ment may begin as soon as it is recognized, but until this is possible, 
it is wiser to wait for secondary evidence. I recall two instances in 



CLINICAL SOCIETY. 73 

which patients who presented themselves for treatment within twelve 
hours of the supposed inoculation had developed a chancre six weeks 
later. 

Doctor Charles H. Chetwood : There seems to be a general ten- 
dency at the present time to question whether syphilis should be treated 
in the primary or in the secondary stage. The reader of the paper has 
emphasized the point that the question is not when to treat it, but that 
it should be treated when the diagnosis has been made. For my part, 
I have always treated it when the secondary eruption appeared, and 
consider it a safe procedure. I would not advise commencing treatment 
earlier unless the presence of the disease should be positively substan- 
tiated by the spirocheta pallida or some other germ. I treat all cases 
according to the general exigencies of each individual condition, and 
the results have been most satisfactory. 

Doctor Joseph H. Abraham : Next to the dermatologist and the 
genitourinary surgeon, the nose and throat specialist sees as many cases 
of syphilis as any of the specialists. They rarely see any primary syph- 
ilis, but many secondary and tertiary cases come to their notice. Per- 
sonally, I have seen five cases. One patient had the initial lesion on the 
lip and the other four on the tonsils, and in one case the upper respira- 
tory glands showed marked symptoms of intoxication. Another marked 
feature is the enlargement of the leutic glands. I agree with the prin- 
ciples laid down by the reader of the paper for the treatment of primary 
syphilis. Secondary syphilis of the larynx should be treated entirely 
by personal rule. I rely upon one drug, carbolic acid. An application 
of ten per cent chromic acid to the larynx gives rise to practically no 
pain and accomplishes the desired result. If the patient is given a 
sufficient amount of mercury for a long enough period of time, he is 
less liable to require the iodides or to suffer from a marked tertiary 
form later. I have never found it necessary to give more than seventy- 
five or eighty grains of the iodid at one dose, and always begin with 
five grains and increase one grain daily or every other day. The absorp- 
tion occurs as desired and the digestive tract is not disturbed. 

Doctor Robert H. M. Dawbarn : I believe the wisest course is to 
begin treatment of syphilis as soon as one is sure of the character of 
the lesion. I do not agree with the statement that the iodid of potas- 
sium has no direct bearing upon the foundation of syphilis. In my 
opinion, overeating and overdrinking may so change the metabolism of 
the hunian system as to render the effects of syphilis more intoxicating. 

Doctor John A. Bodine: The time to begin treatment depends 
greatly on the character of the patient. The primary duty of the phy- 
sician is to effect a cure. If the patient is a highly intelligent one, the 
treatment may begin as soon as the diagnosis is positively made, as 
that character of patient may be depended upon to carry the treatment 
through to its logical conclusion. With a more ignorant patient, it is 
often necessary to first convince him that he is a victim of this disease 
in order to impress upon him the necessity for systematic and long- 



74 ORIGINAL ARTICLES 

continued treatment and in this case the appearance of the skin erup- 
tion following the sore convinces him that he has syphilis. 

Doctor Robinson : I still think the treatment should be begun, if 
possible, during the first stage of the disease. If the patient presents 
what he considers the initial lesion, I recommend a six weeks' course 
of treatment with mercury, and if, at the end of that time, there remains 
any question as to the diagnosis, it is very easy to bring out a small 
lesion as convincing proof. 

REPORTS OF CASES. 
URETHRAL FISTULA AND PROLAPSED KIDNEYS, 

Doctor Charles H. Chetwood: I wish to show a patient on whom 
I operated two years ago for urethritis, and who at the present time 
has an incomplete fistula. When first examined his symptoms seemed 
to point toward the urethra and prostate, the latter being about the size 
of a small orange and very hard. The history indicated a gonorrheal 
infection, and, apparently, a syphilitic abscess of the prostate. The 
patient urinates every half hour, day and night, and the bladder con- 
tains about twelve ounces of residual urine. The appearance of the 
urine is indicative of kidney pus. Both kidneys are prolapsed and the 
right one is very palpable, enlarged and tender. The interesting feature 
of the case is the prolapse of both kidneys without any apparent explan- 
ation. There is no tuberculous history and none suggestive of kidney 
disease. My intention is to drain the prostatic abscess through a per- 
ineal incision, examine the bladder through the opening, and possibly 
catheterize one of the ureters. 

SYRINGOMYELIA OR LEPROSY f 
Doctor John A. Bodine: I desire to present this patient. She is 
twenty-one years of age, and her family history is negative. About six 
years ago she first noticed that she was unable to distinguish the impact 
of the soles of her feet against the sidewalk and began to have aching 
pains in her feet and legs. Later, pus formed beneath callous spots on 
the feet and discharged, leaving sinuses leading down to the metatarsal 
bones. Rest in bed healed the sinuses, but on resumption of her occupa- 
tion they reopened. Pain was present in her spine from the neck to 
the coccyx. She was operated on for contractures of the feet in 1902. 
Her general health is now fair. The soles of her feet are covered with 
multiple perforating ulcers. The discharge is thick, brownish in color, 
and has a peculiar sickening, penetrating odor. There is an abscess 
under the skin in one thigh and another over the sacrum. There are 
marked motor and sensory disturbances of the feet and legs. The case 
is presented for diagnosis, which I think lays between syringomyelia 

and leprosy. 

discussion. 

Doctor William B. Pritchard : I consider this patient an example 
of syringomyelia presenting the exception in a distribution of symptoms 
in the lower rather than the upper extremities, though both are involved. 

The trophic disturbances in the feet, with bladder symptoms, scoli- 



MALTA FEVER. 76 

osis, and, finally, dissociation sensory phenomena, indicate with fair 
clearness the diagnosis. It is not a leprous neuritis, as the nerves show 
no bulbous enlargements and the skin is quite free from the characteris- 
tic plaques. Tabes has been suggested, but there is little in the symptom 
picture to sustain such a suggestion. Absence of the Argyll-Robertson 
pupil, the persistence of one knee-jerk, with absence of true ataxic gait 
and characteristic pains were collectively conclusive in negation. 

ORIGINAL ABSTRACTS. 



MEDICINE. 

By GEORGE DOCK, A. M., M. D., D. Sc, Ann Arbor, Michigan. 

PltOFBSSOII OF MBOBCim IM TMB VMIVmMTT 09 MICHIGAM. 
AND 

DAVID MURRAY COWIE, M. D., Ann Arbor, Michigan. 

riR^T ASSISTANT IN UBOICINB IN TMS VNIVUISITV OW MICMIOAN. 



MALTA FEVER. 
Charles F. Craig ("International Clinics," Volume IV, Fifteenth 
Series, page 89) gives a brief but very valuable study of this interesting 
disease, based upon twelve cases observed by himself. One of the 
twelve seems to have acquired the disease in Washington, District of 
Columbia, the first recorded as originating in the United States. None 
were fatal ; all but one had had one or more previous attacks ; seven pre- 
sented acute exacerbations, five, chronic symptoms. Craig finds the 
symptomatology so complex that no case can be considered as abso- 
lutely typical. The most marked symptom and the one most complained 
of is severe pain in the muscles and around the joints. In acute 
cases it was most intense in the lumbar regions and the extremities. In 
chronic cases it was generally localized around one or more joints, was 
paroxysmal, often leaving one joint and appearing in another. The 
temperature curve is not so characteristic as has been believed. In first 
attacks the undulant type occurs, with a gradual rise, gradual fall, and 
several days of normal temperature. But even in acute cases such tem- 
perature curves are the exception. "In the majority of cases . . . 
the temperature curve, instead of being an aid to diagnosis is the 
reverse, and is the chief cause of mistaken diagnosis." There is an 
anemia, with leucocytosis, the white count ranging from 16,000 to as 
high as 28,000, the increase being in the polynuclears. The kidneys 
seem to escape injury ; even albuminuria is rare. Pain and swelling of 
the joints do not usually occur in first attacks, but during the second, 
third or fourth; rarely not at all. There is moderate swelling, with 
some reddening of the skin. The skin is hot ; there is great tenderness 
on pressure, but no effusion can be detected. The most valuable aid to 
diagnosis is the agglutination test with micrococcus melitensis, first 
observed by Wright, of Netley, and in high dilutions — preferably i 75. 



76 ORIGINAL ABSTRACTS. 

The reaction is marked and immediate. Craig has never found the 
reaction in any other disease ; it failed him once in an undoubted case. 
Malaria, typhoid fever, tuberculosis, pneumonia, septicaemia and 
pyaemia, relapsing fever, and Hodgkin's disease and articular rheuma- 
tism must be differential. The author suggests a wider distribution 
for Malta fever, even in temperate latitudes, than is generally supposed. 

OLD. 



SURGERY. 

By frank BANGHART WALKER, Ph. B., M. D., Detroit. Michigan. 

ntOVBaOOII op SUWLGWMX and OPBRATIVB SUHCBftT IN THE OBTKOIT POSTGRADUATB SCHOOL OP UBDICINB.' 
ADJUNCT PKOPBSSOR OP OPBKATIVB 9URGBRY IN THB DBTROIT COLLBGB OP MBDICINB. 

AND 

CYRENUS GARRITT DARLING. M. D, Ann Arbor. Michigan. 

CUNICAL PROPBSSOR OP 9URGBRT EN THB UNIYRRSITY OP MICHIGAN. 



SCOPOLAMINE AS AN ANESTHETIC AID. 

Without championing any anesthetic or mode of anesthesia, 
Royster sums up in Surgery, Gynecology, and Obstetrics for February, 
1906, his experience with fifty cases. He believes : ( i ) That ether is 
our safest general anesthetic; (2) That ethyl chloride secures the pleas- 
antest primary narcosis; and (3) That the preliminary use of scopola- 
mine with morphine increases the patient's mental resisting power and 
lessens the quantity of ether. 

From its use clinically the writer does not regard scopolamine iden- 
tical with hyocine. He believes it safe in proper doses, not to exceed 
one one-hundredth of a grain. This dose he has sought to use with 
one-sixteenth grain of morphia about one hour before the time set for 
the operation. When the patient is brought in, primary anesthesia is 
induced in about one minute by ethyl chloride sprayed 6n several layers 
of gauze folded over nose and mouth. The ether cone is then used and 
the patient is- ready in four or five minutes. This method, appar- 
ently complicated, he states is really simple and produces sleep safely, 
swiftly, and sweetly. He does not regard scopolamine harmless, how- 
ever, two cases having caused his anesthetizer to doubt whether he 
should proceed. f. b. w. 



GYNECOLOGY. 

By REUBEN PETERSON, A. B.. M. D., Ann Arbor, Michigan. 

PltOPBSSOK OP GTNBCOLOGT AND OB8TBTKXCS IN THB UNIVBIISITY OP MICHIGAN. 

AND 

CHRISTOPHER GREGG PARNALL, A. B., M. D.. Ann Arbor. Michigan. 

PIRST ASSISTANT IN GTNBCOLOGT AND OBSTBTRICS IN THB UNIVBRSITT OP MICHIGAN. 



THE TREATMENT OF ABORTION. 

BoLDT (Journal of the American Medical Association, Volume 

XLVI, Number H) considers at length the treatment of abortion in its 

various stages. He divides abortion into four classes, that is: (i) 

Imminent abortion, in which the symptoms may subside on treatment; 



ORIGIN OF TUBERCULOSIS IN CHILDREN. 77 

(2) Progressing abortion, when the expulsion of the ovum cannot be 
prevented; (3) Incomplete abortion, when the contents of the uterus 
are partially expelled, some portion still being retained; (4) Complete 
abortion. 

The treatment of imminent abortion consists in absolute rest in bed 
and the administration of morphine or codeine as necessary. Tampons, 
ergot, and ice-bags are to be avoided on account of the liability of start- 
ing up uterine contractions. 

Progressing and incomplete abortion, in the absence of symptoms 

of sepsis, are to be treated by first giving a hot antiseptic vaginal douche 

[ and then firmly packing the vagina with gauze. After twenty-four 

j hours the gauze is removed and usually the products of conception are 

! found free in the vagina. In case the os is well dilated and the ovum 

still remains in the uterus it may be possible to introduce the finger 

and effect a manual removal, or the vaginal packing failing, the cervix 

and lower uterine segment may be tamponed and the vagina filled with 

gauze; the subsequent procedures being the same as after vaginal 

packing alone. Should the bleeding be severe when the patient is first 

seen, it is inadvisable to adapt the above plan. Instead, the cervical 

canal should be dilated sufficiently if not already patulous and the 

ovaum or retained decidua removed by the finger or with a placenta 

forceps. Ergot may then be given. 

Complete abortion requires no treatment except rest in bed, vulvar 
irrigation, and the usual measures carried out with puerperal cases. 
Curetment to remove the decidua is unnecessary and hence inadvisable. 

If there is bleeding several weeks after a supposed abortion the 
uterine cavity should be examined and, if necessary, curetted. When 
evidences of infection are present, the uterine cavity should be emptied 
as completely as possible, whether the ovum has been spontaneously 
expelled or not. A curet should be used to remove adherent infected 
membranes or decidua, and an antiseptic intrauterine douche carefully 
given. Great caution is always necessary in curetting the uterus after 
an abortion. 

The general tenor of the article is in advocacy of a conservative, 
expectant method of treatment in all noninfected cases of abortion. 
The author is of the opinion that much harm has come from a tendency 
on the part of many practitioners to adopt really dangerous methods of 
interference in simple cases. c. g. p. 



PEDIATRICS. 

By ARTHUR DAVID HOLMES, M. D..C. M., Detroit, Michigan. 



ORIGIN OF TUBERCULOSIS IN CHILDREN. 

Hynds (Virginia Medical Semi-Monthly, May, 1905) observes that 

tuberculosis in children is a more frequent occurrence than is commonly 

supposed. Fisher says that one-third of the deaths of childhood are 

due to tuberculosis in some form or another, and more frequent under 



78 ORIGINAL ABSTRACTS. 

the age of four years. The bones, joints and lymph glands are the parts 
most frequently affected. Its great prevalence in children during the 
milk-drinking age and the predominance of other types than the pulmon- 
ary would seem to indicate a bovine origin and in communities where 
the milk was Pasteurized the percentage of intestinal forms was less 
than in districts where the milk was fed raw. The British Commission 
found that the tuberculosis produced in cattle by material from human 
and bovine sources was identical in its general effect and in detail. 
Walbach and Ernst came to the conclusion that there was no difference 
in the specificity between tuberculin made from human and bovine 
bacilli and that there was no essential difference in the disease processes 
caused by bacilli from these sources. Rau believes that primary intes- 
tinal tuberculosis and tabes mesenterica are of bovine origin and 
conveyed by milk. Woodhead believes the same. Still thinks that 
tuberculosis of the intestines is often secondary, caused by the swallow- 
ing of the sputtUTi. Behring says "The milk fed to infants is the chief 
cause of consumption." The evidence as to the communicability of 
bovine tuberculosis to infants is so conclusive that there is no longer 
any room for doubt. The only point in question is as to the comparative 
frequency of this mode of infection. This source of infection is 
no doubt very frequent. It is our duty to guard against tubercular 
infection in every possible way and to insist on milk absolutely free 
from tubercle bacilli for infant feeding. The cows should be tested 
with tuberculin and those which react positively should be separated 
from the herd. 



ORTHOPEDICS. 

By IRA DEAN LOREE, M.D., Ann Arbor, Michigan. 

FIRST ASSISTANT IN 8URGBRT IN THE UNIVBRSITT OF MICHIGAN. 



SOME DEFORMITIES ANQ THEIR PREVENTION. 

David T. Bowden, M. D., in the International Journal of Surgery 
for February, 1906. Under this heading he describes some of the more 
common congenital deformities of the lower limbs, their causes, and 
treatment; also some of the acquired forms of deformity, in different 
parts of the body. 

The valuable part of the article must be summed up in the para- 
graphs devoted to the responsibility in neglected cases. The family 
physician as well as the parents must be educated to know the value 
of early intervention in all cases of deformity, especially those of 
congenital origin. Much can be gained even in those cases that reach 
the orthopedic surgeon late, yet complete obliteration of the marks of 
neglect is often impossible. The surgeon must be given the best 
chance and this necessitates early supervision of the treatment. The 
inconvenience and mental suffering of these patients should be im- 
pressed upon the parents' and the family physician should be in a 
position to detect these abnormalities at once. 



INJURIES OF THE EYE. 79 

OPHTHALMOLOGY. 

By WALTER ROBERT PARKER. B. S., M. D. 

rROFBSSOR OP OPHTHALMOLOOT IM TRB UlflVBSSITY OP MICHIGAM. 



INJURIES OF THE EYE FOLLOWING PARAFFIN INJEC- 
TIONS IN THE NOSE. 

Professor W. Uhthoff, of Breslau (Berliner Klinische Wachen- 
schrift, December, 1905), gives the following reports concerning fre- 
quently practiced injections of paraffin in the nose. 

A married woman, aged forty-five, exhibited saddle-nose. While 
there was a history of traumatism, examination rendered a specific 
origin not improbable. There was a history of rheumatism. The heart 
was normal. In all there had been three injections of paraffin, at inter- 
vals of eight and five months, for the treatment of the nose deformity. 
During the third injection the patient suddenly noticed the left eye 
becoming blind. There was no pain, but some lachrymation and sev- 
eral attacks of vertigo were experienced on her way home. There were 
no material inflammatory manifestations, but there was, however, on 
the day following the injection, an ophthalmoscopic picture of embolism 
of the central retinal artery. Vision mV. The diagnosis was confirmed 
eight days later. A puncture on the left side of the anterior chamber, 
followed by massage of the globe, did not change the findings of the 
examination. 

Doctor Uhthoff thinks there is no doubt that a small particle of par- 
affin was the real obstacle that beclouded the arteria centralis retinae, 
ind it must be assumed that the foreign body passed through the pul- 
monary circulation prior to entering the artery. Cases of this kind 
must be regarded as exceedingly rare occurrences. 

An analogous case is that reported by Hurd and Ward Holden ("A 
Case of Blindness Following a Paraffin Injection Into the Nose," New 
York Medical Record, July 11, 1903), in which, after the third injec- 
tion, loss of vision likewise occurred in the corresponding eye under 
the picture of embolism of the central retinal artery. In explanation of 
this case Hurd and Holden are inclined to presuppose a persistent fora- 
men ovale between the two atria, enabling the particle to pass from 
the right atrium into the left, thus obtaining direct access to the arterial 
circulation. 

This assumption seems to Uhthoff somewhat arbitrary, and he does 
not claim the same for his case. The most probable explanation, accord- 
ing to the writer, is that in this case paraffin found its way during injec- 
tion into the venous system and after passing through the pulmonary 
circulation entered the arterial system and consequently also that par- 
ticular arteria centralis retince, 

A similar case was reported by Moll {Ann. des Mai, d'Orielle du 
Lar, et du Phar,, 1902), also one by Rohmer (Ann. d'Occuliste, 1905). 

In Leiser's case, which was reported in the Deutsche medicinische 



80 ORIGINAL ABSTRACTS. 

IVochenschrift, January, 1902, amaurosis of the left eye occurred after 
the third paraffin injection, there being initial collapse and continuous 
vomiting, followed by inflammatory turgescence of the palpebrae, les- 
sening of motility, and symptoms of interocular hemorrhage. Leiser 
here assumes the development of a thrombosis of the vena ophthalmica. 

After speaking of the dangers of liquid paraffin as compared with 
semifluid, and mentioning the means of prevention of embolism sug- 
gested by Leiser, the author reports his second case. 

A male, aged fifty-seven, was kicked in the face by a horse, with 
the resultant deformity of saddle-nose. Three paraffin injections were 
made in 1904, and the result was satisfactory until the end of February, 
1905. About that time, on a rather warm day, patient had exerted him- 
self to the extent of profuse perspiration. Suddenly he felt an itching 
and pressure in both eyes which he proceeded to rub. In the course 
of a few hours they became swollen, and lids and face inflamed. On the 
following day he was unable to open his eyes. Microscopic examina- 
tion of a small piece of skin excised from the strongly swollen palpebrae 
proved that the inflammatory proliferation was caused by penetration 
of the paraffin into the eyelids. For several months patient was 
unable to open his eyes. In order to enable him to open his lids 
at least to some slight extent and to use his eyes, it was necessary to 
remove the hard, tumor-like proliferation of the lids. Microscopic 
examination was in harmony with the clinical findings. The inflam- 
matory proliferations are occasionally not sharply circumscribed but 
coalesce diffusely into the surrounding tissue. Consequently these are 
not sharply circumscribed and encapsulated paraffin tumors, but infil- 
trations of the tissue with paraffin particles and strong interstitial 
inflammatory proliferation. In fact at this time large quantities of par- 
affin in substance are no longer demonstrable in the newly-formed 
tissue, but the exceedingly numerous giant cells of foreign bodies indi- 
cate that diflFuse paraffin particles in the tissue have decided the point 
of origination for the new formation of the strong inflammatory tissue. 



OTOLOGY. 

By R. bishop CANFIELD, A. B.. M. D.. Ann Arbor. Michigan. 

PROPBSSOR OP OTOLARYNGOXX>GY IN THB UNIVERSITY OP MICHIGAN. 
AND 

WILLIAM ROBINSON LYMAN, A. B., M. D., Ann Arbor, Michigan. 

DBMOMSTRATOR OP OTOLARYNGOLOGY IN THB UNIVBRSITY OP MICHIGAN. 



ACUTE BILATERAL MIDDLE EAR SUPPURATION FOL- 
LOWING AN INTRANASAL OPERATION, AND 
RESULTING IN DEATH FROM PYEMIA. 
Otto J. Stein, M. D., in The Laryngoscope, Volume XVI, Number 
I. The salient points in this case are: 

( I ) An acute suppurative process in both ears, following an intra- 
nasal operation. 



MIDDLE EAR SUPPURATION. 81 

I (2) Absence of all pain or tenderness in or about the ears subse- 

j quent to the incision of the drum membranes on the third and fifth days 

j respectively. 

j (3) A profuse aural discharge, showing only diplococci, continu- 

ing for sixteen days. 

(4) A most profound deafness. 

(5) The maintenance of a high temperature for sixteen days, with 
no decided changes excepting one complete remission on the seven- 
teenth day. 

(6) Absence of rigors and perspiration. 
^ (7) Pus in the urine. 

(8) Diarrhea. 

(9) Metastasis in the knee-joint and side of the thorax. 

( 10) A complicating angina of the soft palate and arches, with the 
membrane showing diplococci catarrhalis infection, the same as found 
in the ears. 

The patient was a female, forty-one years old, thin and weak, but 
complaining of no particular ailment. Two days after removal of the 
posterior end of the left inferior turbinate she suffered from earache on 
the right side. The membrane was incised on the third day. On the 
fourth day the left ear ached and the membrane was incised. After the 
incisions all pain disappeared and both ears discharged freely. The 
temperature from the first remained high with no remissions. Doctor 
Stein saw the case on the thirteenth day of the first ear symptoms, at 
which time the temperature was 102**, pulse 120, regular and full, res- 
piration 28. Patient complained of no discomfort but deafness was such 
that one had to shout into her ears, and there was no history of deaf- 
ness previous to the operation. She was nauseated and had vomited 
that morning. There was present a mild diarrhea but no abdominal 
tenderness. Chest examination was negative. The secretion from the 
ears ran into the throat and there was a membrane over the soft palate 
and uvula which was not at all painful. Pus escaped freely from the 
large openings in the membranes. Exposed bone was detected in the 
middle ear of the left side. No mastoid tenderness. Temperature 
, 103.6**, pulse 125. Blood examination gave 4,000,000 red, 15,000 white, 

hemoglobin eighty per cent. Ear examination was negative. 

On the sixteenth day the patient complained of pain about the right 
j knee. The urine examination on the following day showed pus, albu- 

I min, streptococci and staphylococci. The temperature dropped to 96.4°. 

The left mastoid was opened; the bone was hard and white, showing 
no signs of necrosis. The sigmoid sinus was exposed throughout its 
entire length and found apparently healthy ; the tip of the mastoid was 
removed ; and cells far into the zygoma taken away. The only evidence 
of inflammation was in the antrum and middle ear where the membrane 
was thick and covered with granulations. No openings could be found 
into the cranial fossa. 

The following day the patient was, at times, in a comatose state and 



ORIGINAL ABSTRACTS. 



j the right mastoid was opened with the hope of finding some avenue of 

j venous infection. A condition similar to the left was found, the sinus 

I was exposed and found apparently normal, so it was not opened. The 

I patient was in her rocmi an hour after leaving it and her condition 

improved so that she recognized her family, but the coma gradually 
deepened and she died ten hours later. No autopsy could be obtained. 
The most common avenue for septic material to gain entrance to the 
circulation from the middle ear and antrum is through the large sinuses. 
This could not be discovered. Septic material has gained entrance to 
the circulation through the small veins and this has occurred as a result 
of osteomyelitis of the mastoid, and the question arises whether suffi- 
cient absorption could have taken place from the middle ears and antra 
to have caused the fatal result. On account of the sudden marked deaf- 
ness the extension of the disease through the labyrinth must be consid- 
ered. This might have taken place through the internal meatus, or 
along the aquaeductus vestibuli or aquaeductus cochlae, or along the 
veins leaving the inner ear. r. b. c. 



LARYNGOLOGY. 

By WILLIS SIDNEY ANDERSON, M. D., Detroit. Michigan. 

ASSISTANT TO THB CHAIR OP LAKTNGOLOGT IN THB DBTKOIT COLLS6B OP MBDICINB 



ORBITAL AND MENINGEAL INFECTION FROM THE 
ETHMOID CELLS. 

James F. McCaw (American Journal of the Medical Sciences, 
August, 1905) reports a case in a man, forty years of age, who had 
had catarrh and nasal obstruction for years. Severe cerebral symptoms 
developed leading to the patient's death. 

Postmortem showed that the infection originated in the ethmoid 
cells, broke through the os planum, stripping the periosteum from the 
roof of the orbit, extending outward and downward to the external 
angular process of the temporal bone, and there passed out to form the 
subperiosteal collection of pus described in the paper. These cases are 
rare but nevertheless cerebral infection from the nose takes place often 
enough to warrant more care on the part of practitioners. 



THE TREATMENT OF EMPYEMATA OF THE MAXILLARY 
SINUS THROUGH THE NOSE. 
George L. Richards (Journal of the American Medical Association, 
September 16, 1905), divides etiologically these cases into those of 
nasal and dental origin. The author advises the treatment of the sinus 
by the nasal route. If of dental origin extract the tooth, treat the infec- 
tion, and allow the wound to close. When not of dental origin puncture 
high underneath the inferior turbinal and wash out the antrum. If this 
does not suffice enlarge the opening sufficiently so that it will remain 
open during the required time of treatment. The antrum can then be 
curetted or packed with gauze as the case requires. 



SPASTIC CONSTIPATION. 

PROCTOLOGY. 

By LOUIS JACOB HIRSCHMAN, M. D., Detroit, Michigan. 

CUMXCAL PKOFUSOm OP PKOCTOLOGT IH THB OmtOtT COLLBGX OP MBOICINB. 



LOCKING THE BOWELS FOR FROM TEN DAYS TO 
TWO WEEKS. 

•Howard A. Kelly, in the February, 1906, number of Surgery, 
Gynecology, and Obstetrics, concludes, after discussing a series of 
twelve cases of plastic work around the rectum, that an enforced 
obstipation lasting from eight to fifteen days is of great value in the 
management of these cases after operation. His patients are put on 
a diet of egg-albumin and water ; this being practically all assimilated, 
and leaving no residue in the bowel. The first twenty-four hours, the 
patient receives no food whatever; on the second day one and a half 
ounces of albumin in water at two feedings; on the third day three 
ounces divided into fiyf or six feedings about three hours ap>art; on 
the fourth day three and a half ounces in the same manner; fifth day 
and daily till the tenth or fifteenth day, six ounces per diem. The 
bowel is moved at the end of the period by giving a half ounce of 
licorice powder, followed in some cases by an oil enema, and perhaps 
the next morning by a half ounce of salts. One of the most important 
factors in securing the first evacuation is to^ have the patient lying 
in the Sims position, so as to obviate straining. Scybala will not 
form even after this long period of intestinal stasis, if milk is eliminated 
from the diet, and a perfectly soft stool is procured from the albumin 
diet. 



"SPASTIC CONSTIPATION. 

Dudley Roberts, in the Brooklyn Medical Journal, for March, 
1906, claims that this form, in which the retention of feces is due to a 
spastic contracture of a part, or the whole of the lower bowel, often 
supervenes upon a long-standing atonic constipation. He quotes sev- 
eral authorities to support his contention that as high as twenty-five 
per cent of all cases of habitual constipation are of this variety. 
Usually this spastic condition is due to neurasthenia, hypochondria, or 
hysteria, or it may be a reflex from disease of other organs. The stools 
are not hard, are of small caliber, or of a "sheep-dung" shape, and are 
passed mainly by the pressure of the diaphragm and abdominal muscles. 
The large balls of hard fecal matter, so common in atonic constipation, 
are absent in this condition. Palpation reveals some part or even the 
entire colon contracted to the size of the index finger, and it can be 
rolled under the palpating hand. 

The treatment of this condition is the treatment of the underlying 
neurotic condition. These patients are usually poorly nourished and 
undeveloped. Suggestion is of value on those patients who are con- 
tinually worrying about the action of their bowels. It is stated that 



84 ORIGINAL ABSTRACTS. 

the coarse vegetables and fruits, so valuable in atonic constipation, 
are strong irritants to the mucosa in this condition. Fats are well 
borne, as well as sugars and honey. Warm sitz baths and abdominal 
compresses are of value, while cold applications and massage are con- 
traindicated. All cathartics are discarded, as the intestine has an over- 
plus of contractile force. Hyoscyamus and belladonna in suppositories 
are.of distinct value. Rectal and oral exhibition of olive oil is one of 
the best forms of treatment. The amount given by mouth is only 
limited by the patient's ability to digest it, while the enemata vary from 
five to fifteen ounces, warmed to 99° Fahrenheit and given at night and 
retained till morning. This is done daily for a week and then gradu- 
ally "tapered off." Bromides and chloral are given by mouth in some 
cases, and spasm of the sphincter is relieved by forcible dilatation under 
gas or ether anesthesia. The cure of the condition may require months 
of treatment. 



NEUROLOGY. 

By DAVID INGLIS, M. D.. Detroit, Michigan. 
pROFissom OP Nsmvous and mbntal dissasbs in thb pbtroit collbgs op mbdicinb. 

AND 

IRWIN HOFFMAN NEFF, M. D., Pontiac, Michigan. 

ASSISTANT PHYSICIAN AT THB BASTBKN MICHIGAN ASYLUM. 



BRAIN TUMORS: A STUDY OF CLINICAL AND POST- 
MORTEM RECORDS BEARING ON THEIR OPERA- 

BILITY AND THEIR SYMPTOMATOLOGY. 
G. L. Walton and W. E. Paul (Journal of Nervous and Mental 
Diseases, August, 1905) contribute a paper based on a study of autopsy 
records and specimens of two hundred twenty-one cases of brain tumor. 
The number of operative cases from the author's point of view was 
three per cent. The clinical features considered are: convulsions, 
headache and vomiting, mental symptoms, condition of pupils, and 
reflexes. As the writers have been concerned particularly in the inves- 
tigation of various reflexes, their interpretation of the findings of the 
reflexes is of considerable import. They state that there is need for an 
enormous amount of detailed labor before an exact idea can be reached 
of the locations of the mechanism concerned in the various- reflexes and 
their interpretations. Considerable variation was observed in the con- 
dition of both the deep and superficial reflexes in brain tumors; and 
although, as they say, their findings were insufficient, they believe that 
even the meager findings they noted, suggest that it is worth while to 
carry on the study of the brain as an important integral part of the 
reflex mechanism. Concerning the knee-jerk, they believe that the fact 
is, however, established that the knee-jerk not infrequently disappears 
in brain tumor ; and while confessing their inability to critically analyze 
all the findings which they recorded, they submit that they are not 
easily recognizable with any theory which accepts the spine as the sole 



THE SECRET NOSTRUM EVIL. 85 

seat of the reflex arcs. The authors conclude the paper with the fol- 
lowing suggestion : "The facts here collected are presented merely as 
stiggestivc, not as demonstrative or as representing final results. The 
main object in this branch of the communication is to direct attention 
to the importance of more complete and careful observaticwis of the 
locations and the periods in which central growths affect the reflexes, 

with a view to furthering the final analysis of the cerebral reflex \ 

mechanism/' i. h. n. ' 



THERAPEUTICS. 

By DELOS LEONARD PARKER, Ph. B., M. D., Detroit, Michigan. 

LBCnimSB OM MATBIIIA MBDICA IN TMB DBTKOIT COLLSOB OV MBDICIMB. 



THE SECRET NOSTRUM EVIL. 

For some time unmistakable signs have appeared in medical 
journals and medical conversations that go to show that the medical 
profession is fast becoming wearied with unscientiflc therapeutics. 
No more telling sign of this kind has ccwne to the notice of the profes- 
sion at large than that exhibited by Frank Billings, M. D., of Chicago, 
in a paper entitled "The Secret Nostrum Evil," read before the 
American Medical Association, July, 1905, and published in the 
December 2, 1905, number of the association journal. 

The doctor begins by saying that "proprietary medicine" does not 
necessarily stamp a preparation or remedy as a nostrum. Some prop- 
prietary medicines are patented, a process that causes their owners 
to file at the patent office their formulas and their mode of prepara- 
tion. For a small fee any person can get from the patent office a copy 
of the information bearing on the remedies that have been recorded 
there. Whether or not the patented remedy or remedies are prepared 
in conformity with the information furnished the patent office is 
another story. Whether or not a patented remedy contains the same 
ingredients one year that it does another is also another story. What- 
ever the actual facts, however, the profession could easily get on 
without patented remedies and fare better with older and simpler 
combinations. 

The so-called copyright preparations do not differ in any essential 
particular from "patent medicines." Both are protected by copyright 
for an indefinite period, and both, as a rule, are mixtures of several 
ingredients, prepared with the idear not that they will correct disturbed 
functions of the body, but that they will sell and bring money to the 
coffers of somebody. Doctor Billings quotes Doctor H. C. Wood, Jr., 
as follows: 

"A much more elusive and therefore dangerous evil lurks in the 
class of mixtures which attempt to cloak their secrecy with a deceptive 
show of frankness. I think you will grant that the physician is rarely 
justified in the use of remedies concerning which he has no knowledge, 
and I maintain that the publication by a drug firm, of whose integrity 



g6 ORIGINAL ABSTRACTS. 

the physician is absolutely ignorant, of a professed list of ingredients 
of some mixture is not sufficient knowledge to parilon or to warrant 
the uses of that remedy. In the first place, if the published formula 
be correct, it is not enough to know simply the composition of a mix- 
ture, the exact quantities must also be known ; there is a vast difference 
between the eflfects of one grain and of one hundred grains of opium. 
Moreover, there is no means of knowing that the formula is a true 
one, for many of these corporations do not hesitate to pervert the 
truth." 

Preparations of reliable manufacturing chemists, made up of 
known ingredients, and recommended to the profession simply for 
their palatability or convenience of form are not included in the list 
of preparations to be condemned. 

Doctor Billings closes his paper as follows : 

"What is the cause of the nostrum evil ? There are several. 

"(i) Pharmacology and therapeutics are neglected relatively by 
many of our medical schools. Anatomy, physiology, pathology, diag- 
nosis, et cetera, are emphhasized and too often the usefulness and limit- 
ations of drugs are neglected. Too frequently drug nihilism is taught. 
If the student were fully taught the physiologic action of drugs, the 
art of prescribing, preferably single remedies or in simple combination, 
using if he desires the pharmacopeial preparations prepared by reliable 
manufacturing pharmacists, and at the same time if he were taught 
when not to rely on drugs, but frankly to prescribe for his patient a 
course of hygienic measures which alone would accomplish all that 
would be required, he would not be the willing dupe of the nostrxun 
vendor, as he now is. 

"(2) The reput^ible manufacturing pharmacists deserve great 
credit for the improvement they have made in pharmaceutical prod- 
ucts. They have afforded us official preparation^ in the form of pills, 
tablets, syrups, tinctures, extracts, et cetera, which are elegant in 
appearance, often palatable and usually potent. For this advance in 
pharmacy, a distinct credit to our country, we owe them our thanks. 
Unfortunately, many of them have not stopped at this point, but have 
manufactured their own special mixtures which are just as objection- 
able as the products of the special manufacturers. They, too, have 
been active with their agents in visiting physicians and in distributing 
'literature.' This encourages drug-giving in specific mixtures for 
special symptoms, and is wrong. With one hand they do good work, 
with the other much evil is done. 

"(3) The nostrum makers at first copied the methods of the reli- 
able manufacturing chemists, in exploiting their products, but they 
have gone a step farther and have reached a point where one may say 
that they have subsidized the medical press. I know I am on dan- 
gerous ground when I make this statement, but right here is the chief 
cause — and the remedy. How many of our so-called medical journals 
are subsidized by medicine manufacturers I do not know, but all physi- 
cians know as well as I that there are many, and I do not refer to the 



MILK PRESERVATION. 87 

so-cailed house organs. I unhesitatingly affirm that one-half of the 
medical journals of the country. would be out of existence if it were 
not for the nostrum advertisements. Under the circumstances, there- 
fore, can we expect these journals to say anything? Need we be sur- 
prised that scarcely a journal published the official report regarding 
the acetanilid mixtures, when the preparations hit were the best paying 
advertisements in the country? 

"What is the remedy? Publicity. The enlightenment of the pro- 
fession. The truth regarding not only what the preparations contain, 
but who makes them. Certainly no honest manufacturer will object 
to this last proposition, and no honest physician will put up with less 
than the former. 

"The Council on Pharmacy and Chemistry has been created to 
investigate the nonofficial preparations, to find out the truth about 
them, and to publish its findings. It is not necessary to repeat here 
the results of the work already done by this body. All physicians 
have read, or may read all about it. In my opinion there has been no 
movement undertaken by the American Medical Association that will 
be so far reaching as this one to rid us of the blight of the nostrum evil. 
For the first time, we see the possibility of the elimination of a part, 
at least, of this curse to American medicine. It is the first practical 
solution offered of a most difficult problem." 



EDITORIAL COMMENT. 



A QUICK MEANS OF PRESERVING MILK. 
The fertility of milk as a culture medium for bacteria, as evidenced 
by the rapidity with which organisms increase in the liquid and the 
consequent putrefaction, has prompted many efforts by scientists to 
discover some ready means for preserving this excellent nutritive 
article without altering the character of its composition. Experiments 
have demonstrated that in the short space of one hour one cubic centi- 
meter of milk may provide for the generation of over six thousand 
organisms, and that after the lapse of twenty-four hours this growth 
may increase to the magnitudinous proportions of about eleven million. 
These observations were made with milk procured under ideal con- 
ditions, and obviously the number of microbes would be decidedly 
greater were the milk secured from an unhygienic dairy. Refriger- 
ation affords an admirable means of checking the growth of bacteria, 
but since this process is not always convenient its impracticability for 
general purposes is apparent, and indeed the same may be said of the 
various other preservative measures known to science. 

* * * 

It therefore seems appropriate to chronicle a relatively simple 
method employed with great success by Renard, a Frenchman, which. 



88 EDITORIAL COMMENT. 

while not intended as a preservative for long periods, has given prime 
results in checking bacterial growth for from two to three days, or 
even longer time. An interesting feature in the preservation is that 
no antiseptics, such as formol, salicylic acid, or borax, are employed, 
the mere admixture of the milk with oxygenized water sufficing to 
retard the growth of organisms through decomposition of the water, 
the milk being unaffected and absolutely pure and sweet at the termi- 
nation of the process. In experiments recently conducted at Rouen, 
the investigator obtained excellent results by pouring a two-per-cent 
solution of water, oxygenized at twelve volumes, into the milk. The 
results already achieved indicate the unadvisability of. employing the 
water in stronger than three-per-cent solution, since the decomposition 
of a more powerful solution in the milk may lead to undesirable out- 
come. After treatment with a three-per-cent solution, milk was pre- 
served at a temperature of 1 1 ° centigrade, without the slightest trace 
of acidity for ninety-five hours, while preservation could be maintained 
for only thirty-two hours at a temperature of twenty degrees. 

* lit 3|C 

That milk preserved by the above method is absolutely pure was 
demonstrated in one of the dispensaries at Rouen, where fifty-seven 
infants were fed on the product with uniformly good effect. The 
results obtained with boiled milk were not favorable, since the oxygen- 
ized water forms certain combinations with the elements of the milk 
which have undergone change in boiling. Experiments conducted by 
Nicolle and Duclaux upon the comma bacillus, the bacillus of cholera, 
the bacillus coli, and certain pus-producing organisms demonstrate 
that the oxygenized water process does not destroy pathogenic bacteria 
with any degree of certainty. The question may be asked, then, why 
is not Pasteurization a more acceptable method, since it insures the 
destruction of all organisms, with the possible exception of the tubercle 
bacillus? So far as the destruction of bacteria is concerned the 
Pasteur method is ideal, but it does not insure preservation, and the 
milk, after being subjected thereto, is devoid of many of its nutritive 
properties. 



ANNOTATIONS, 

STUDIES IN SIMIAN VERNACULAR. 
Professor Garner, the eminent scientist, who is the discoverer of 
the monkey language, is to undertake a second expedition into the 
wilds of Western Africa to further his studies in simian vernacular. 
The professor carries with him a green cage in which, while making 
observations, he is secure from the ravages of the serpent and ferocious 
beasts of the jungle. By means of intricate apparatus he was enabled, 
on a former expedition, to record certain inarticulate sounds from afar, 
which observation taught him to decipher. By means of definite 



OBSERVATIONS IN ANIMAL OPTICS. 89 

articulation he was able to put to flight an entire nKmkey horde, and 
with equal dexterity could assemble the quadrumana by imitating their 
expression for "all is well." He learned to recognize their sound for 
food and water and for many other things, and could in course of 
time converse, so to speak, with the tribe. The contemplated expe- 
dition will doubtless be more fruitful in its results, however, as Gamer 
will take with him the most perfect phonographs ever produced, that 
record may be made of the language of the wild. 



THEORIES APPERTAINING TO APPENDICITIS. 

Mahler, in a German periodical, discusses appendicitis and theo- 
rizes on the factors leading to its causation. The French theory that 
particles of porcelain from cooking utensils are responsible for the 
affection must be abandoned, since in one thousand operations Krem- 
mer found no trace of such substance in the appendix. According to 
Mahler, heredity undoubtedly plays an important role in the causation 
of the disease, as is evidenced by repeated attacks in the same family. 
This author ventures the suggestion, however, that meat may be a 
provocative factor, and cites the prevelance of appendicitis in America, 
England, and the city of Hamburg, where meat is the chief food staple, 
in support of this idea. The fact that appendicial attacks occur more 
generally among people of wealth in Europe is further empharfzed, as 
the economic- conditions existing abroad preclude the poorer classes 
from meat indulgence. 

OBSERVATIONS IN ANIMAL OPTICS. 
Doctor Lindsay Johnson, the English ophthalmologist, who has 
been studying the optic apparatus of various animals, has made some 
valuable discoveries which, according to Lankester, the noted zoologist, 
will require the entire rearrangement of one section of zoology. That 
man bears a close relationship to the lower forms is reiterated in 
Johnson's findings. The similarity of the eye of man and that of the 
anthropoid apes, according to this investigator, is suggestive of the 
Darwinian theory. Each is equipped with a highly complex arterial 
and venous system, and parallel vision is characteristic of both. The 
observations disclose the probability that the canine family is a product 
of two ancestries, since in the dog may be found both the round- and 
oval-eyed types. The first species is undoubtedly the result of an 
admixture of hyena blood. The eye of animals exposed to the chase — 
the squirrel, hare, et cetera — is so situated that the vision is unlimited, 
the animal being able to see in all directions, without altering position. 
The fact was likewise observed that all rodents squint, but the signifi- 
cance of this peculiarity remains unascertained. The parallel vision is 
especially typical of the higher forms, and the lower in the scale of 
development the animal is classified the less liability is there to this 
optical adjustment. Perhaps the most interesting feature of Johnson's 



go EDITORIAL COMMENT. 

research is his theory as to the nature of the corpus nigcr in the eye of 
the horse, which has caused so much speculation among scientists. 
This structure is found in nearly all tropical animals — the camel, onegar, 
and antelope — and fulfills the function of protecting the eye from the 
sun's rays. Its presence in equinae affords a possible means of tracing 
the ancestry of the horse. 



CONTEMPORARY. 



PHYSICIANS AND PHILOSOPHERS. 

[PROPISSOll CHAHLBS WILLIAM SUPER, OP OHIO UNXVBRSITT, IN POPULAH SCIBNCB MONTHLY.] 

{C^mtinutd from page 44.) 

Apropos of the intimate relationship existing between the stu-^.v 
of nature and the healing art, we find that the Romans as early as the 
time of Cicero called a natural philosopher physicus, while the science 
itself was called physica, both words having been borrowed from the 
Greek physikos, that which pertains to nature, from physis, nature, 
in the somewhat restricted sense of the term as used in antiquity. But 
in medieval Latin physica had become the equivalent of mededna and 
physicus that of medicus. In the older English, physic means both 
natural philosophy, the modern physics, and the medical art as well as 
drugs. The restricted signification 'to purge* and 'a purge' is com- 
paratively recent. 

Shakespeare uses both doctor and physician, the former generally in 
the sense of teacher. Doctor also occurs in Middle English and later 
Chaucer speaks of a 'doctour of Phisik.' In classical Latin the term 
doctor means teacher, a sense in which it is used by Cicero, Horace 
and others. It had no connection with medicine. In modern French 
physicien means one who occupies himself with physics, but in the 
older language it had the signification of the English physician. The 
French medecin, physician, is evidently from the Latin medicinus, a 
derivative from medicus, while our medicine, a remedial drug, is from 
the same word in the feminine gender. In German the connection 
with the English physician is preserved by Physikus alone, a term used 
to designate an official whose functions correspond in the main with 
our health-officer. Here too the term Doktor has long since usurped 
the more specific Artst, and Doktorei is occasionally used for medicine, 
'doctor's stuff.' The Gothic word lekeis, which is the Anglo-Saxon 
laece and the English 'leech' has nothing in common with either 
except the meaning. This term doctor again brings to the physician 
the same title that ib borne by the scholar. Although it is given in 
several departments such as law, theology, music, philosophy, and so 
on, to the common man both in German and in English countries the 
doctor represents only the physician. This is explained by the fact 
that in most communities the only man or men bearing the title were 
physicians. Of late years, however, especially in the United States, 



PHYSICIANS AND PHILOSOPHERS. 91 

doctors of divinity have becwne so common, not to mention other 
doctors, that the designation has reached the stage of painful uncer- 
tainty. What it now represents can only be determined by an investi- 
gation of each individual on whom it has been conferred. 

No more convincing testimony to the small progress made in the 
healing art from the earliest times until a little more than a century 
ago need be asked for than is offered by a comparison of the average 
length of human life as given by Herodotus and that currently 
accepted until quite recently — three generations to a century. In fact 
most life insurance associations have not yet learned that this average 
is above forty years. Anatomy had made great progress and the struc- 
ture of the body was minutely known, but until the germ theory of 
disease and antisepsis were established, therapeutics was largely a 
matter of tradition and routine; of empiricism and individual skill. 
When one reads of the incessant wars that kept a portion of the male 
inhabitants constantly occupied in military enterprises, directly or 
indirectly, one is inclined to believe that the average of human life 
must have been shorter than it was held to be twenty or twenty-three 
centuries ago. There is no room to enter upon a discussion of the 
problem here; suffice it to say, the loss from disease was probably no 
greater, and the losses in the armies probably much less relatively than 
in modem times. For it is well known that the killed in battle are but 
a small portion of those whom war deprives of life. It is probable 
that never before or since has any country suffered such ravages as 
did Germany during what is called the thirty years war. That the 
sanitary condition of ancient Greece must for the most part have been 
fairly good is attested by the rapid recuperation of most of the city- 
states after a disastrous war. But then there were no large cities 
like those of modern times, in which the population increases much 
faster than the adoption and enforcement of sanitary measures. 

It will hardly be considered surprising that disease in any form 
should early have stimulated men to reflection. This is true at least 
of those living under conditions where there was more or less freedom 
of action and where affairs had not yet settled down into the lethal 
routine that characterized the social life of most of the people of the 
ancient world anterior to the appearance of the Greeks. The succes- 
sion of day and night; the changes of season that follow each other 
regularly, and the meteorological conditions that accompany them, 
would be taken as a matter of course. But the vicissitudes of the 
human system, whether gradual, rapid or sudden, when not the result 
of accident or attributed to the malevolence of evil spirits, naturally 
led to inquiry as to their causes. The next step was in quest of 
prophylactics and curatives. This sort of reasoning, of philosophy, 
was not obnoxious to the charge that Socrates brought against the 
philosophy of his day, namely, that it was concerned wholly with 
things that were of no benefit to any one and with problems to which 
no answer could be found. 

^ [to be continued.] 



d2 MEDICAL NEWS. 

MEDICAL NEWS. 



PROFESSOR ERNST ZIEGLER, PATHOLOGIST. 

Doctor Ziegler^ whose death occurred recently, was born in the 
neighborhood of Berne, Switzerland, in 1849. He studied medicine in 
his native city and also at Wiirzburg, and received his doctor's degree 
at Berne in 1872. He qualified as privatdocent at Wiirzburg, occupy- 
ing this position for three years, when he went to Freiburg in Breisgau 
as assistant and later became extraordinary professor. In 1881 he filled 
the chair of pathology and morbid anatomy at Ziirich, in 1882 he went 
to Tiibingen in a similar capacity, and in 1889 returned to Freiburg, 
where he remained as professor of patholc^y until the time of his 
demise. Doctor Ziegler was a prolific writer and investigator, and con- 
tributed articles on inflammation, tuberculosis, rickets and neoplasms to 
various periodicals, but the greatest expression of his work is embodied 
in "Ziegler's Pathology," which was first published in 1881, and through 
which he is chiefly known to American students and physicians. Besides 
being professor and author he was likewise editor of two of the most 
important German publications on pathology — ^the Beitrdge zur allge- 
fneinen Pathologic und pathologischen AnatonUe and the Zentralblatt 
fiir allgemeine Pathologic und pathologische AnatonUe. He was 
engaged in the revision of his text-book at the time of his death and 
had so far progressed with the work that with slight further revision 
it may be accepted as the final expression of his opinion on pathology. 
He was highly esteemed as a man, and his ability as a lecturer has 
been attested for long by students from many climes. 



MINOR INTELLIGENCE. 



A BILL has been introduced in the Massachusetts legislature to pro- 
hibit the publication of advertisements referring to sexual diseases. 

A LATE ordinance of the city of Toronto provides that the houses of 
persons succumbing to tuberculosis shall be disinfected by the local 
health officers. 

MiLAN^ Italy, is designated as the next meeting place of the Third 
International Congress of Electrology and Radiology, which will con- 
vene in Sptember, 1906. 

The Protestant missions have been instrumental in establishing the 
Union Medical College, of Pekin, China, which institution was opened 
for instruction February 13, 1906. 

A BILL has been introduced in the New York legislature forbidding 
the marriage of imbeciles, epileptics, insane, or feeble-minded persons. 
The measure also prohibits the marriage of sound persons to feeble- 
minded. 



MINOR INTELLIGENCE. 08 

The announcement is made that Karl von Noorden has been 
appointed to fill the chair at the University of Vienna made vacant by 
the death of Professor Nothnagel. 

Queen Amelie, of Portugal, who is a doctor of medicine, will be 
honorary president of the Fifteenth International Medical Congress, 
which meets in Lisbon, April 19, 1906. 

The Health Department of Havana reports that three patients, suf- 
fering from mild attacks of yellow fever, are still confined in Las 
Animas Hospital. No new cases have recently been reported. 

The Iowa State Board of Medical Examiners has made a ruling to 
the effect that diplomas granted by schools which allow advanced stand- 
ing for work done outside of medical schools shall not be recognized. 

The City of Mexico is in the throes of an epidemic of typhus fever. 
The disease is attributed principally to bad sanitary conditions in the 
city, and stringent measures toward remedying them are being enforced. 

The plans submitted for the new army hospital at Washington 
have been approved by Secretary Taft. The estimated cost of the 
building is $300,000, Congress having limited the appropriation to this 
amount. 

The Chicago Women's Club has inaugurated a campaign against 
venders of impure milk, and the various female organizations of the 
city will be asked to subscribe $1,500 annually to provide a salary for a 
competent milk inspector. 

Doctor Lehman H. Dunning, of Indianapolis, a well-known gyne- 
cologist and for several years professor of gynecology and abdominal 
surgery in the Indiana Medical College, died at his home on January 4, 
1906, aged fifty-five years. 

Doctor Clara Marshall has resigned the Chair of Materia 
Medica and Therapeutics in the Woman's Medical College of Pennsyl- 
vania. The doctor has been connected with the teaching force of the 
institution for over thirty years. 

A SITE has been chosen in the town of Pittsford for Vermont's new 
tuberculosis sanitorium. The institution is a gift to the state from 
Senator Redfield Proctor, and the projectors anticipate the completion 
of the buildings by next winter. 

The passage of a bill in the New York Assembly, on March 6, pro- 
vides for the appointment of two more health commissioners for the 
city — one for the Boroughs of Manhattan, Richmond, and Bronx, and 
one for the Boroughs of Brooklyn and Queens. 

The will of the late Doctor George S. Hyde provides that $50,000 
be turned over to the Harvard Medical School upon the death of E. P. 
Hyde and Mrs. Aniie M. Sargent, brother and sister of the deceased. 
The doctor was connected with this institution prior to his demise last 
year. 



94 MEDICAL NEWS. 

At the twenty-ninth annual meeting of the Illinois State Board of 
Health, which was held recently at Springfield, Doctor George W. 
Webster, of Chicago, was elevated to the presidency, and Doctor James 
A. Egan, of Springfield, was reelected to the secretaryship. 

Dissension exists between the physicians and druggists at Bayonne, 
New Jersey, because the latter persist in counter prescribing. A state 
law prohibits any person except a physician frc«n prescribing for the 
sick, but the druggists have engaged counsel and will institute a test 
case. 

A SUM of $8,000 has already been subscribed toward the erection of 
a $10,000 memorial to the late Doctor Joseph Leidy in consideration 
of his invaluable contributions to the natural sciences. The monument 
will be presented to the city of Philadelphia, the field in which the 
scientist worked and died. 

Reports recently submitted to the Mississippi legislature by the 
State Board of Health disclose an expenditure of over $43,000 during 
the past year in consequence of the yellow fever epidemic. Fifteen 
localities were infested, the total record showing eight hundred thirty- 
seven cases and sixty-one deaths. 

The sum of $13,000 was realized from the New York German 
charity ball which was held in January. Of this amount $2,300 was 
given to the German Hospital and Dispensary, and smaller amounts 
were donated to Saint Mark's Hospital, the West Side German Dis- 
pensary, and Saint Francis' Hospital. 

Doctor Samuel R. Wooster, late president of the Grand Rapids 
Academy of Medicine, died from the effects of a surgical operation on 
February 6, aged sixty-six years. Doctor Wooster was a graduate of 
Yale and during the Civil War was connected with several Michigan 
regiments in the capacity of army surgeon. 

»The will of Charles L. Yerkes, the deceased street railway mag- 
nate, bequeathes $800,000 for the purchase of a site and erection of hos- 
pital buildings thereon in the Borough of Bronx. Provision is also 
made for the maintenance of the institution. The income arising from 
a sum of $5,000,000 will be utilized for this purpose. 

Professor Ernst von Bergmann, the eminent German physician, 
has been raised to life membership in the upper house of parliament by 
the German Emperor. Professor von Bergmann is the author of the 
work on surgery which bears that name, and is the first physician to be 
elevated to the dignity of membership in the German parliament. 

The next meeting of the Association for the Advancement of 
Science will be held in New York City on December 27, 1906. At the 
recent meeting in New Orleans the following officers were elected for 
the ensuing year: President, William H. Welch, of Johns Hopkins; 
general secretary, John F. Hayford; secretary of council, F. W. 
McNair. 



AUTOINTOXICATION IN DISEASE. 95 

After several setbacks the osteopaths have renewed their efforts to 
establish recognition of their cult in the state of New York. The 
Davis bill, which is intended to create an osteopathic examining board 
under the Regents of the State University, was recently given public 
hearing before the Senate Judiciary Committee. Several physicians 
and laymen spoke in opposition to the bill, contending that its passage 
would permit persons unqualified, by reason of meager medical knowl- 
edge, to engage in medical practice. The only supporters of the bill 
were four osteopaths from different New York cities. 



RECENT LITERATURE. 



REVIEWS. 

THE READY REFERENCE HANDBOOK OF DISEASES OF 

THE SKIN.* 

This last edition of Doctor Jackson's well-known and popular hand- 
book contains the addition of much new material in text and illustra- 
tion. It is among the best of handbooks, and while the alphabetical 
arrangement of diseases does not commend itself to the specialist or 
teacher, it will appeal to the practitioner who wishes to get at the gist of 
pathology, diagnosis, and treatment of a given case — if only tentatively 
— ^in the shortest time. The style is clear and concise, and the book will 
advance the position the former editions held as a valuable and trust- 
worthy guide in the care of diseases of the skin. A useful appendix 
contains suggestive formulae for external applications, as well as for 
internal medication. w. f. b. 

♦By George F. Jackson, M. D. Fifth edition, thoroughly revised, 
making a 12-mo. volume of 676 pages, with ninety-one engravings and 
three colored plates. Cloth, $2.75, net. Lea Brothers & Company, 
Philadelphia and New York, 1905. 



SELF-POISONING OF THE INDIVIDUAL.* 
The reprinting of this well-known work seems to indicate a con- 
tinued demand. This being so, it is unfortunate the whole book was 
not rewritten. It is hard to patch the stuff of the last twelve years' 
work upon the well-worn garment of the former time, and Doctor 
Oliver has only made this clearer by his well-meant endeavors. The 
things that made the first edition popular are still here — ^the assurance 
of certainty, the simple faith in antiseptics, but they fall on stonier 
ground than before. Let us hope the next edition will give us what 
the first promised. G. d. 

♦By Ch. Bouchard^ Professor of Pathology and Therapeutics; 
Member of the Academy of Medicine and Physician to the Hospitals, 



96 RECENT LITERATURE. 

Paris. Translated, with a Preface an^ New Chapters added, by 
Thomas Oliver, M. A., M. D., F. R. C. P., Professor of Physiology, 
University of Durham ; Physician to the Royal Infirmary, New Castle- 
Upon-Tyne; formerly Examiner in Medicine, Royal College of Physi- 
cians, London. Second revised edition. Crown octavo, 342 pages. 
Extra cloth. Price, $2.00, net. F. A. Davis Company, Publishers, 
1914-16 Cherry Street, Philadelphia. 



PRACTICAL PEDIATRICS.* 

This treatise on the medical and surgical diseases of childhood is 
certain to rank as one of the best books of the kind for the busy practi- 
tioner or for the student preparing for examination. It is brief and to 
the point, as the author has omitted superfluous material. The Ameri- 
can translator has made many additions and inserted notes which 
enhance the value of the book. An excellent chapter devoted to the 
"Materia Medica and Theurapeutics of Childhood" concludes the work. 
The book is most attractively executed and the parts are well arranged. 

A. D. H. 

*A Manual of the Medical and Surgical Diseases of Infancy and 
Childhood. By Doctor E. Graetzer, Editor of the Centralblatt fur. 
Kinderheilkunde and the Excerpta Medico. Authorized translation, 
with numerous Additions and Notes, by Herman B. Sheffield, M. D., 
Instructor in Diseases of Children, and Attending Pediatrist(0. P. D.) 
New York Post-Graduate Medical School and Hospital ; Visiting Pedi- 
atrist to the Metropolitan Hospital and Dispensary, et cetera. Pages 
XII-544. Crown octavo, flexible cloth, round comers. Price, $3.00 
net. F. A. Davis Company, Publishers, 1914-16 Cherry Street, 
Philadelphia. 

THE PHYSICAL EXAMINATION OF INFANTS AND 
YOUNG CHILDREN.* 

An inexpensive, neat little book, full of many practical suggestions 
for those who desire to acquaint themselves with the various methods 
of examining children. The illustrations are clear in detail. There is 
only one subject of importance in the examination of children the 
author fails to clear up for the reader, that is, how to induce the child 
to become so "pleased to meet you." The majority of the illustrations 
present a smiling nurse and doctor and a perfect angel of a patient, 
almost like the catatoniac whose arm stays where you put it. 

*By Theron Wendell Kilmer, M. D., Adjunct Attending Pediatrist 
to the Sydenham Hospital ; Instructor in Pediatrics in the New York 
Polyclinic Medical School and Hospital, New York; Attending Phy- 
sician to the Summer Home of Saint Giles, Garden City, New York. 
Illustrated with fifty-nine half-tone engravings. i2mo, 86 pages. 
Bound in extra cloth. Price, 75 cents, net. F. A. Davis Company, 
Publishers, 19 14- 16 Cherry Street, Philadelphia. 



% Jtesician aiilr Surgeon 

A PROFESSIONAL MEDICAL JOURNAL. 



VOLUMB XXVIII. MARCH, 1906. NUMBER III. 



ORIGINAL ARTICLES. 



MEMOIRS. 



CONGENITAL LUXATION OF THE HEAD OF THE RADIUS.* 

REPORT OF TWO CASES. ANALYSIS OF FIFTY-ONE CASES. SUMMARY. 
CER TAIN O THER CONSIDER A TIONS. COXCL USIONS. 

By WILLIAM E. BLODGKTT. M. D.. Detroit. Michigan. 

The concurrence of two new cases of congenital luxation of the 
head of the radius, with failure to find a thorougli review of the sub- 
ject directly based on the observed facts, has led to the present paper. 
Nearly all the cases here included are referred to by Powers,* Blumen- 
thal,^ Bonnenberg,^ or Abbott,* to whom the author is indebted for 
most of his data; but it is believed that a uniform analysis of each 
case and collation and summary of the entire group is needed. 

The plan of the paper, therefore, is to (I) report the author's two 
cases, (II) analyse the fifty-one cases, (III) summarize the group, 
(IV) consider certain features of the subject not covered by the sum- 
mary, and (V) draw conclusions. 

I.— REPORT OF CASES. 

Case L — A girl, fifteen years old. No miscarriages or other sug- 
gestion of syphilis in family history. No abnormalities in parents or 
in brothers or sisters. The trouble in the arms was first noticed when 
it was found that the young baby could not hold a lump of sugar on 
either palm. Three years ago while arranging her hair, the patient 

♦Presented by invitation at the nineteenth annual meeting of the American 
Orthopedic Association, at Boston, June 6-8. 1905. 



98 ORIGINAL ARTICLES. 

had sudden pain in the left elbow upon attempting to extend it; no 
pain when the elbow was at rest in flexion. This difficulty in exten- 
sion continued several months. An anesthetic showed that the obstacle 
to extension was muscular. The difficulty gradually disappeared. 
Neither elbow has at any time been swollen or tender. No other 
deformities. Excellent general health. The chief complaint is of par- 
tial disability of either arm, illustrated by the patient's inability to 
grasp a plate or a spoon with the thumb on the upper surface. There 
is also unusual liability to fatigue in the arms. 




FIGURE I. — RIGHT ELBOW, CASE I, SHOWING ANTERIOR DISLOCATION OF HEAD OF 
RADIUS, ELONGATION OF RADIUS, AND FUSION OF RADIUS AND ULNA. 

Patient is well developed and nourished. Examination of parts 
other than the arms, negative. The forearms are fixed in respect to 
rotary motion in full pronation. Flexion and extension are free and 
strong. Hyperextension beyond straight sixteen degrees on left and 
twenty degrees on right. Relation of condyles and olecranon appar- 
ently normal. Distal to the external condyle and the capitellum, the 
space iiormally occupied by the head of the radius is vacant. On the 
llexure surface of the elbow, anterior to this vacant space, is plainly 
felt a hard, globular body, size of the index finger, moving with 



CONGENITAL LUXATION OF RADIAL HEAD. 



09 



movement of the forearm. The tendon of the biceps passes down on 
the inner side of this body. No atrophy apparent. No other abnor- 
malities of arms. The two elbows are alike. 

Radiographs show on each side an anterior luxation of the radial 
head, excessive length of the upper end of the radius, absence of the 
normal slight anterior concavity of the lower end of the shaft of the 
humerus, and cancellated bone fusion of the radius above the tubercle 
with the ulna. Radiographs of the forearms and wrists show nothing 
abnormal, except that bones are small for age. 




FIGURE II. — LEFT ELBOW OF NORMAL GIRL, SAME AGE. SAME POSITION AS IN 

FIGURE I. 

The temporary inability to extend the left elbow without pain is 
to be explained by a sprain, to which such an imperfect joint would 
be especially liable. Excision of the radial head, the only operative 
procedure to be considered, was believed unindicated by the amount 
of disability present. 

Case II. — (Through courtesy of Doctor Daniel LaFerte, Detroit). 



100 



ORIGINAL ARTICLES. 



A boy, six years old. No syphilitic history or abnormality in family. 
Since birth, the forearms were fixed in extension and pronation. 
Radiographs taken two years ago show bilateral, anterior luxation of 
the radial head, elongation of the upper end of the radius, and no bone 
fusion. Owing to the permanent extension, the disability was great. 
About two years ago, Doctor LaFerte excised the upper end of the 
radius on each side, taking care not to disturb the insertion of the 




FIGURE III.- 



LEFT ELBOW, CASE I, SHOWING DISLOCATION ELONGATION, AND FUSION. 
PRONATKD POSITION. 



biceps. This was followed by riianipulative mobilizations, which, how- 
ever, were discontinued by the patient sooner than advised. The child 
also had double club-foot, which was operated on with good result. 
When the boy was seen by the author two years after the operation, 
the mother stated that the boy could now feed himself, and that the 
arms were improved, although the child still grasped objects with 
the thumb underneath. Passive flexion on both sides was found to 
reach to a right angle, and passive extension to within twenty degrees 
of straight; no power, however, on either side in flexion or extension. 



CONGENITAL LUXATION OF RADIAL HEAD. 



101 



The right elbow is permanently pronated, and the left is in ninety 
degrees of pronation and allows a few degrees of rotary motion. 

Radiographs show what appears to be a partial regeneration of the 
heads of the radii in the anterior position. 




FIGURE IV.- 



-LEFT ELBOW OF NORMAL GIRL, SAME AGE. 
FIGURE III. 



SAME POSITION AS IN 



II.— ANALYSIS OF FIFTY-ONE CASES. 













C/3 

H 

is Q 


5 . 












2 



>: 


i« 


-< < 

oi Z 


^ 


''■ 


CASE 




Q 




n 



Si 


Si 


THER 

BFORM 

lES 


REMARKS 




ss 


M 


>-) 


S 


bd H 


b. < 


Q H 




(i) Bonnenbcrg* 


F 


R 


For- 
ward 


Free flex'n. 
155" ex- 
tension. 


Yes 


No 




Excision head of ra- 
dius and lower end 
ulna. Osteotomy 
shaft radius to 
straighten. Result: 
pronated position, 
with slight passive 
and no active supi- 
nation; free flexion 
and extension. 


(2) Dupuytren* 




Both 


Back- 
ward 




Yes 






Necropsy. 



102 



ORIGINAL ARTICLES. 



(3) Dupuytren* 



(4) Servier' 



(5) Herskovitz* 



(6) Homphrey* 



(7) Mitscherlich" 



(8) Allen" 



(9) Pyc-Sinith»2 



(10) Phillips" 



{ii)Hccle" 



M 



Both 



Both 



Both 



M 



M 



Both 



Both 



Both 



Both 



Both 



•J 



Back- 
ward 



Back 
ward 



Back 

ward 



For- 
ward 



For- 
ward 



Back 

ward 



Back 
ward 



Back- 
ward 



Back 
ward 



o 

2 



Supination 
limited. 
No mention 
flexion or 
extension. 

Half pro- 
nation to 
fall prona- 
tion. 

Free flex- 
ton. 120'' 
extension. 



Extension 

free. 
Flexion on 

R. to 7o% 

L.to 110**. 

Snpinated. 

Extension 
only to 
right an- 
gle. No 
rotation. 



Extension 
free. 

Flexion 
nearly 
free. 

Semipro- 
nated. 

Slight ro- 
tation. 

Normal, 
but supi- 
nation 
weak. 



o < 



Yes 



Yes 



Yes 



Yes 



en 

& 

s 

•< •< 

at Z 
O ^ 

^ 9 

k. < 



No 



Yes 



at 



Absence 
lower 
part of 
left ulna. 

Club- 
foot 

Defect of 
knees. 



Forearm 

concave 

toward 

radical 

side. 



Defect 

lower 

ulna. 

Club- 
foot 



Hyper- 
trophy 
external 
condyle. 



REMARKS 



Radial head, upon 
rotation of farearm, 
circumducts in circle 
of 3 c m. radius. 



Necrcipsy only. 



Complete excision 
elbow. Death. 
Specimen shows no 
contact at all be- 
tween head of radius 
and ulna. 

Necropsy. No his- 
tory of presence in 
early life. 



Noticed early in life. 
In family of eleven, 
eight had joint de- 
formities. 

Noticed shortly after 
birth. 



Noticed early in life. 
Loose- jointed. In- 
telligince backward. 
Right always luxated 
— left, usuidly. 



CONGENITAL LUXATION OF RADIAL HEAD. 



103 



CASE 



(i2)Machenhauer>* 



(13) Adams^* 



(14) Adams^' 



(15) Dcvillc" 



(16) Senftlebcn** 



(17) Adams'* 



(18) Adams" 



(19) Cruvcilhicr** 



(20) Cruveilhicr** 

(21) Sandifort* 

(22) Sandifort* 

(23) Dubois* 

(24) Vcrneil* 

(25) Sandifort* 



M 



M 



M 



M 



Both 



Both 



o 

< 
X 
D 
•J 



For 
ward 



One 



R 
One 
One 
One 
One 

R 



Out- 
ward 



Out. 
ward 



Out- 
ward 



Back- 
ward 



Back- 
ward 



Back- 
ward 



In- 
ward 
and 
for- 
ward 






Extension 

to 165° 

Flexion to 

Supination 
and prona- 
tion free. 

Free ex- 
cept in ex- 
tension. 

No exten- 
sion or 
flexion. 

Supination 
and prona- 
tion free. 

Freer than 
normal. 



Normal. 



In position 
of semi- 
flexion 
and full 
pronation. 



Extension 
limited. 

No supina- 
tion. 



Pronated. 



No supina- 
tion. 



«3 

< u. 
o o 



Yes 



Yes 



Yes 



Yes 

2 in. 



Yes 



Yes 



Yes 



Yes 



< < 
t4 Z 



o ^ 

^ s 

u. •< 



No 



No 



Yes 



gas 

H M M 

O Q H 



No. 



Other de- 
formities 
of elbow. 

Defects 
in other 
joints. 



Deficien 
cy middle 
of ulua. 



Defici- 
ency 
shaft of 
ulna. 



Forearm 
concave 
on ulnar 
side. 



Necropsy. Radial 
head excessively 
large. 



Necropsy. Soft parts 
normal. Fibrous 
band in place of mid- 
dle of ulna. Forearm 
concave on ulnar side 

Fibrous cord in place 
of middle of ulna. 
Forearm concave on 
ulnar side. 

Preparation. fio 
trace of capitellum. 



Preparation. "Cari- 
ous" process in joint. 



Preparation. 



Necropsy. 



Preparation. 



104 



ORIGINAL ARTICLES. 



CASE 


X 

M 

F 


R 




< 

Back 

ward 


> 

H 

1 ' 

Suptnafion 

limited. 

Semiflexed* 


J 

c ■< 

5t 

^ 1 

^ 
-1 a: 

Yes 


3 

< < 

Si 




REMARKS 


(26) Bessel- 

Hagen» 




External 
condyle 
hypertro- 
phied. 
Gigant- 
ism of 


Excision head of rad- 
ius, foUowed hyman- 
ipulalions under an- 
eiithesia. Result 
one year after opera- 
lion: normal mobil* 


» 


1 










arms* 


ity* 


(27) Bessel- 

Hagen^ 




K 


back- 
ward 


AH motions 
limited. 

Semipro- 
nated and 
semiflexed. 


Ves 




Various 

exostoses 

and de- 

fecis. 

Forearm 

smaller 


Ulna undeveloped, 
and deficient at car- 
pal end. 








!■ 






and con- 


















cave on 
I ulnar 
side. 




(28) Bessel- 

Hagen» 


M 


L 


Back 
ward 


Extension 
onlv 

limited* 


Ves 




Varioui* 
defects* 
Forearm 
smaller 
and con- 
cave on 
ulnar 
^ide. 


Eiead circumducts 
in rotalioD of £ore- 
arro. 


(29) Smith" 


F 


One 


For- 
ward 


From 90^ 
to nearly 
straight 
Pronation 
and supina- 
tion lim- 
ited. 






External 
condyle 
enlarged* 
Congeni- 
tal luxa- 
tion of 
wrist and 
knee. 


No trochlea or capi- 
tellum< 


(30) Smith" 


F 


One 


<( 


Slight ex- 
tension 
from 90*" 
permanent 
flexion. 
Pronation 
and supi- 
nation 
limited. 


Yes 


Yes 


External 

condyle 

enlarged. 

Deficient 

ulna. 


No capitellum. Hole 
for radial head be- 
tween imperfect 
trochlea and exter- 
nal condyle. 


(31) Toppich» 


M 


L 


(« 


Free 


Yes 






Tuberculosis other 
elbow. 


(32) Leisrink** 


M 


Both 




Extension 
and flexion 
nearly free. 
Supination 
and prona- 
tion much 
limited. 






Luxata- 
ble left 
ulna. 


Resuscitated after 
delivery by vigorous 
means. First noticed 
at third year. 



CONGENITAL LUXATION OF RADIAL HEAD. 



105 



CASK 



(33) Abbott* 



(34) Abbott* 



(35) Abbott* 

(36) Abbott* 



(37) Abbott* 



{38) Abbott* 



(39) Abbott* 



<40) Abbott* 



M 



M 



M 



Both 



For- 
ward 



Both' " 
Both '* 



Buih 



Botb " 



M Br>th 



Back 

ward 
and 
in- 
ward 



> 

i 


J 

4 bi 






Extenfiion 

and flexion 
free. Fixed 
in fietni- 
pronation. 


Ye> 


Yes 
witli 

cen- 
ter of 
oulfi 

CMtEw 


No 


Ex ten a ion 
and flex ton 

free. Fixed 
in fieroi- 
pronation. 


Yes 


V€S 


No 


As above, 
but left has 
only sHgbt 
check to 
supination. 


Ves 


Ves 
It 


11 


Extension 
and fleaion 
free. Fixed 
in £]mi- 
pronation* 


Yes 1 


Ye« 




ft 


Yes 


Ye» 


tl 


ti 


li 


n 


it 


All motions 
restricted. 


Yes 




Club- 
foot. 
Disloca- 
tion 
patella. 



Noticed early in life. 
The presence of the 
lesser sigmoid cavity 
and the smooth arti- 
cular cartilage on the 
head indicate to Ab- 
bott that the primary 
lesion is the over- 
growth of head and 
neck, resulting in fu- 
sion (due probably to 
the center normally 
forming the coronoid 
process). 

Noticed early in life. 



Noticed early in life. 
Not seen by Abbott, 
but credibly reported 
to him to be entirely 
similar to his other 
cases. 

Noticed early in life. 
Not seen by Abbott, 
but credibly repoted 
to him to be entirely 
similar to his other 
cases. 

These seven cases 
occured in one fami- 
ly, covering four gen- 
erations. 

Dissection. 
Apparently due to 
deformity of lower 
ends of humeri. 
Capitellum well- 
formed, and larger 
than usual. 



106 



.ORIGINAL ARTICLES. 



(41) Abbott^ 



(42) Voigt" 



(43) Schmidt" 



(44) Blumentb&l' 



(45) Powers* 



(46) Ambard" 



M 



M 



M 



(47) Bcrgtold* 



(48) Hamilton" 

(49) Guerin*" 



One 



One 



Both 



Back 
ward 
and 
out- 
ward 



Back 
ward 



For 
ward 



Back 
ward 



o 



Extension 

slightly 

limited. 
Flexion 

free. 

No supina- 
tion beyond 
midpoint. 



Excessive 
flexion to 
140° of ex- 
tension on 
R. Free 
flexion and 
extension 
on L. Al- 
most no 
supination 



For- Almost no 



Both 



ward 
and 
out- 
ward 



Out- 
ward 



Both 



Both 
Both 



supination 
No active 

flexion. 
Passive 

flexion to 

Free and 
strong. 



For- 

word 



'^ 9 
o •< 

2g 



Extension 
and flexion 
free. Fixed 
in prona- 
tion. 

Normal. 



Yes 



Yes 



Yes 



< < 

o ^ 

^ 5 

u. < 



No 



Yes 



No 



H M S 
O Q H 



Defect of 
radius on 
other 
side. 

Defect of 
radius on 
affected 
side. 

Forearm 
on R. 
shorter, 
and rad- 
ius con- 
cave in- 
ward. 



No 



Nasal 
caries. 
Syphili- 
tic? 



Yes 



No 



Noticed early in life. 
Capitellnm well- 
formed, and larger 
than usual. 



Radial bead luxata- 
ble upon extension. 



Sister, father, and 
paternal grand- 
father said to have 
same deformity. 
Radiographs. 



Noticed three days 

after birth. 

Left arm shorter. 

Radiograph. 



Noticed early in life. 
Applied for treat- 
ment for excoriations 
over prominence of 
head of radius on 
outer side of either 
elbow. 

Luxation believed by 
Ambard to be con- 
genital effect of 
hereditary syphilis. 



Generally loose- 
jointed. 



CONGENITAL LUXATION OF RADIAL HEAD. 



107 













OD 


2 












g 




g^ 




^ 




CASE 


X 


S 


I 





1^ 

^ 9 


THER 

EFORM 

lES 


REMARKS 




M 


n 


D 





2 2 


D S5 






en 


M 


•J 


X 


M M 


U. «< 


Q H 




(50) LaFertd«» 


M 


Both 


For- 


Nearly fixM 


Yes 


No 


Club- 


Noticed early in life. 
Excision radial 








ward 


in exten- 






foot. 










sion and 








heads. Result after 










pronation. 








two years: passive 
but no active flexion, 
no rotary mobility. 


(51) Blodgett** 


F 


Both 


4* 


Extension 

and flexion 

free. 
Fixed in 

pronation. 
Hypcrex- 

tensible. 


Yes 


Yes 


No 


Noticed early in life. 




III.— SUMMARY. 




(J) Sex. 




Male 




22. 61.1%. 


Female 




14. 38.9%. 


Unrecorded 




15- 


Of bilateral cases : 






Male 




17. 77.3%. 


Female 




5. 22.7%, 


Unrecorded 


(2) Side, 


3. 


Both 




25- 50.0%. 


One only 




25. 50.0%. 


Unrecorded 




I. 


Of unilateral cases : 






Right 




9. 56.2%. 


Left 




7. 43.8%. . 




Un 


recoi 


rded 






9 




• 



(j) Direction of Lujfation. 



Backward 

Forward 

Outward 

Inward 

Unrecorded 



23. 


46.0%. 


20. 


40.0%. 


6. 


12.0%. 


I. 


2.0%. 


I. 





In the bilateral cases the direction of luxation was always the same on the 
two sides. 



108 



ORIGINAL ARTICLES. 



(4) Mobility. 
Table A. 
Backward. Forward. Outward. Inward. Unrecorded. Total. 



Freer than 

normal 

Normal i. 5.6%. 

Restricted 17. 94-4%. 

Unrecorded 5. 



1. 16.7%. 
I- 5.9%. 3. 50.0%. 
16. 94i%- 2. 33-3%- 
3. 



I. 24%. 

5. 11.6%. 

37' 96.0%. 



Table B. 



Extension. 
Flexion. 
Pronation. 
Supination 



Free or 
nearly free 
(including cases 
fixed in the ex- 
treme of motion.) 

21. 60.0%. 14. 40.0%. 

22. 64.7% 12. 35-3% • 
27. 62.8%. 16. 37.2%. 
12. 27.9%. 31. 72.1%. 



Restricted. Unrecorded. 



16. 

17. 
8. 
8. 



Table C* 
Backward. Forward. Outward. Inward. Unrecorded. Total. 



Extension 
free or 
nearly free. 

Flexion 
free or 
nearly free. 

Pronation 
free or 
nearly free, 
including 
cases fixed 
in full 
pronation. 

Supination 
free or 
nearly free. 



3. 13.0%. 13- 65.070. 5- 83.3%- 



II. 47.8%. 6. 30.0%. 5. 83.3%. 



21. 



22. 



14. 60.9%. 5. 25.0%. 6. 100.0%. 

2. 8.7%. 4. 20.0%. 5. 83.3%. 

(5) Elongation Upper End of Radius. 

In backward luxations 18. 

IS. 



27. 



12. 



In forward luxations 
In outward luxations 
Direction not recorded 
Total 



78.3%. 
75.0%. 
66.7%. 



4. 
I. 
38. 74.5% 



*The precentages in Table C. are based on the whole number of luxations in the 
direction under consideration; thus 100 % of the outward luxations have free pronation 
because six have this movement free and there are only six outward luxations in all. 



CONGENITAL LUXATION OF RADIAL HEAD, 
(d) Bone Fusion Upper Part Radius and Ulna. 



10» 



In backward luxations 
In forward luxations 
In outward luxations 
In inward luxations 
Total 


6 (4 single, 2 double). 

ID (4 single, 6 double) . 

0. 

I (single). 

17 (9 single, 8 double). 


26.1%. 
50.0% 

33.3% 


::ases with fusion: 






No rotation 
Almost no rotation 
Unrecorded 
Pronated position 
Semipronated position 
Unrecorded 


14- 
2. 
I. 
6. 
7. 
4. 




(7) Other Deformities. 




Bone deficiency in forearm 7 
Club-foot 5. 





Other deformities of elbow. 

(besides those directly refer- 
able to the luxation of the head 
of the radius) 

Lateral curve of forearm. 
(3 concave on ulnar side, 
I concave on radial side). 

Other joints defective 

Total 



4. 

2. 

-22. 



431%. 



IV.— CERTAIN OTHER CONSIDERATIONS. 

(i) Incidence, 

Stimson'^ quotes Kronlein's'* statement *'that the records of Von 
Langenbeck's polyclinic show 90 congenital dislocations of the hip, 
5 of the shoulder, 2 of tlTe head of the radiuis, and i of the knee.'' 
Congenital dislocation of the hip, the cotnmonest of the congenital 
dislocations, was found by Chaussier once m 23,293 infants born at 
the Maternite, although Parise, in 332 hip dissections of all the children 
who died at the Hospital 'des. En f ants Trouves, found congenital dis- 
location of the hip three times.^* 

(2) Congenital Character. 

The arguments for the congenital character of these dislocations 
of the head of the radius are: 

(i) Discovery of the condition early in infancy, without preceding 
trauma. 

(2) The fact of being bilateral, although Bartels"* reports a bilateral 
dislocation of the head of the radius in a boy, acquired by pushing a 



110 ORIGINAL ARTICLES. 

heavy cart, and Pungaud'* reports an instance in which both radial 
heads were dislocated by violent parturition. 
C3) Concurrence of other deformities. 

(4) Inheritance. 

(5) Pronounced bone changes; but bone fusion, similar to that 
occurring in the cases of dislocations, is reported without dislocation 
by Drenkhahn'^ (one case), JoachimstaP® (three cases), Kiimmell" 
(three cases, one bilateral), and Hamilton** (one case, bilateral.) 

(6) Greater mobility than to be expected in acquired dislocation. 

Upon applying these arguments to the 51 cases reported as con- 
genital, it is seen that the congenital character of some is more or less 
in doubt, judging by the evidence presented. In many of these cases, 
however, the reports, if full, would probably confirm the assertions 
of the respective authors, and, on account of the difficulty of making 
a satisfactory standard for discrimination, and on account of the large 
number of the cases that are congenital beyond reasonable doubt, it 
has been thought wise to include all the 51 reported cases in compiling 
the summary. 

(3) Etiology. 

Blumenthal refers the lesion to the pronated position of the fetal 
elbow in human gestation and the special exposure of the head of the 
radius in this position to injury dependent upon deficient liquor amnii. 
This would account for the usual limitation of supination in these cases, 
as well as in the cases of congenital interference with supination with- 
out luxation.*® 

Ambard^^ refers his case (Number 46) to congenital syphilis, and 
Bottomley** reports two cases of Cotton's in which congenital syphilis 
produced acquired dislocation of the head of the radius similar to the 
congenital dislocations. 

Heredity appears to be operative in Pye-Smith's, Abbott's, and 
Blumenthal's cases (Numbers 9, 33, 34, 35, 36, 37, 38, 39, and 44). 
In the seven cases of Abbott's, which cover four generations in one 
family, the individual transmitting the lesion was only once himself or 
herself subject to it. 

Hamilton** classifies the theories of causation of congenital dislo- 
cations in general as follows : 

(i) Physiological: original or developmental defect. 

(2) Pathological: contraction, paralysis, lax ligaments, hydrathro- 
sis, or some other diseased condition of the joint. 

(4) Treatment. 

Four operated cases are reported: 

(i) Complete excision of the elbow in Mitscherlich's case (Number 
7) by Langenbeck, for relief of great limitation of flexion and perma- 
nent supination, in a double forward dislocation. The result was not 
observed, as the patient died shortly after operation. 



CONGENITAL LUXATION OF RADIAL HEAD 111 

(2) Excision of radial head only and manipulations, in Bessel- 
Hagen's case (Number 26) of backward dislocation, for relief of 
pronated and semiflexed position and limitation of all motions. Result, 
one year after operation: normal motions. 

(3) Excision of radial head and distal end of ulna, and osteotomy of 
shaft of radius, in Bonnenberg*s case (Number i) of forward luxa- 
tion, for limited extension and permanent supination. The lower end 
of the ulna was excised because rotary motion was found to be impos- 
sible without this excision. The shaft of the radius was divided to 
straighten the arm. The result was free extension and flexion and 
a position of pronation, but no rotary motion. 

(4) Excision of radial heads and manipulations, in LaFerte's 
bilateral case (Number 50) of forward luxation, for permanent exten- 
sion and pronation. Result two years after operation : passive but no 
active flexion, and no supination. 

In one of the cases reported by Bottomley,** of acquired backward 
luxation but similar to the congenital type, excision of the heads of the 
radii greatly improved the mobility, which had been restricted in all 
directions. 

Thus in two of the three cases of congenital luxation in which the 
head of the radius was excised, free active flexion and extension was 
obtained, and in the third case passive flexion was obtained. Rotation, 
however, was restored to only one of these three cases, though in one 
of the other two the preferable position of pronation was substituted 
for that of supination. 

In none of the operated cases was there bone fusion, complicating 
the luxation. 

v.— CONCLUSIONS. 

Nearly two-thirds of the cases of congenital luxation of the head 
of the radius are male. 

Equally common on the right and left sides. 

The commonest direction of luxation is backward; forward luxa- 
tions nearly as common ; outward luxations only once in eight. 

In nearly all of the combined cases, mobility is more or less 
restricted ; but in half the outward luxations, mobility is free. Supina- 
tion is the motion most often limited ; extension, next most often. In 
backward luxations, flexion is the motion most often free; while in 
forward luxations, extension is the motion most often free. 

Elongation of the proximal end of the radius is present in three- 
quarters of the cases, and is about equally frequent in the luxations 
in the diflFerent directions. 

Bone fusion of the upper parts of radius and ulna present in one 
third of the cases. In all the cases with fusion, there is no or almost 
no rotary motion, and the forearm is pronated or semipronated. 

In nearly half of the cases, there is some other deformity, oftenest 
partial deficiency of ulna or radius. 

Congenital luxation of the head of the radius is very rare. 



112 ORIGINAL ARTICLES 

The congenital character of some of the fifty-one reported cases is 
open to doubt. 

The factors to be considered in etiology are the special embryology 
of the elbow, congenital syphilis, heredity, and the conditions leading 
to congenital luxations in general. 

Excision of the head of the radius is indicated by considerable 
restriction of flexion or extension in uncomplicated cases; doubtful, 
in cases with only rotary motion restricted; probably cc«itraindicated, 
in cases with practically free flexion and extension but permanent 
pronation and bone fusion. 

REFERENCES. 

* Powers, C. A. : The Journal of the American Medical Association, 1903, XLI, 

page 165. 
' Blumenthal, M. : Zcitschr. f. orthop. Chir., 1904, XII, i u. 2 Heft, S. 181. 
' Bonneberg : Zcitschr. f. orthop. Chir., 1893, II, page 376. 

* Abbott, F. C. : "Transactions of the Pathological Society of London," 1891-2, 

XLIII, page 129. Also: Lancet, 1892, page 800. 

* Giirlt : Beitrdge zur Vcrgleich. path. Anat. der Gelenkrankheiten, 1853, page 

317, Dupuytren's case. Through Bonnenberg. 
Stimson, L. A. : "Treatise on Dislocations," 1888, page 349, same (Dupuy- 
tren's) case. 

*Malgaigne, J. F. : Die Knochen-briiche u. Verrenkungen, 1856, Band II, page 
631, from Dupuytren's oral report. Through Bonnenberg. 

"Servier: Gas. Hebdom. de Med. et de Chir., 1872, IX (second series), page 
214. 

"Herskovitz, L. : Wien. med. Presse, 1888, XXIX, page 217. Through Bon- 
nenberg. 

'Humphrey: Med. Chir. "Transactions," XLV, page 296. Through Stimson. 

'" Mitscherlich: Archiv. f. klin. Chir., 1865, VI, page 218. Through Stimson. 

" Allen : Glasgow Medical Journal, 1880, XIV, page 44. Through Stimson. 

"Pye-Smith: Lancet, 1883, II, page 993. Through Stimson. 

*' Phillips : British Medical Journal, I, page 773. Through Stimson. 

"Heele: Lancet, 1886, II, page 249. Through Stimson. 

" Machenhauer : Centralblatt f. Chir., XIX, Nr. 13. Through Bonnenberg. 

"Adams, R. : "The Cyclopedia of Anatomy and Physiology," 1839, H, page 75. 
(Powers.) 
Also: Dublin Journal of Medical Science, Volume XVII. Through Bonnen- 
berg. 

" Deville, A. : Bui. de la Soc. Anatom. de Paris, 1849, XXIV, page 153. Through 
Bonnenberg. 

"Senftleben: Archiv. f. path. Anat. von Virchotc, 1869. XLV, page 303. 
Through Bonnenberg. 

'•■ Cruveilhier, J. : "Traite d'Anat. Path. Generale," 1849, page 479. Through 
Bonnenberg. 

*® Bessel-Hagen, F. : Ueber Knochcn u. Gelenkanomalien, Laugcnbeck's Archiv. 
f. klin. Chir., 1891, XLI, page 420. Through Bonnenberg. 

" Smith, R. W. : Dublin Quarterly Journal of Medical Science, 1850, X. Through 
Bonnenberg. 

*' Smith, R. W. : Dublin Quarterly Journal Medical Science, 1852, XII, page 208. 
Also: Proceedings of the Pathological Society of Dublin, 1841-50, I, part 2. 
page 185. 



LABOR DURING SECOND STAGE. 113 

"•Toppich: "Beitrag zur Kenntniss der angeborenen Luxationen des Capitellum 
Radii," 1888. Through Bonnenberg. 

••Leisrink: Deutsch. Zeitschr, f. Chir., 1873-4, IV, page 16. Through Bonnen- 
berg. 

"Voigt: Wagner's Archiv. f. Heilkunde, 1863, IV, Seite 26. Through Bon- 
nenberg. 

*• Schmid : Zeitschr. f. orthoped, Chir., 1893, Band. II. Through Blumenthal. 

" Ambard: Rev. d'Orthop., 1901, II (second series), page 173, Through Powers. 

*• Bergtold, W. H. : Annals of Surgery, 1891, XIV, page 370. Through Powers. 

*• Hamilton : 'Tractures and Dislocations," Philadelphia, 1880, sixth American 
edition, page 888. 

••Guerin: "Recherches sur les Luxations Congenitales," Paris, 1841. Through 
Hamilton. 

•* Present article. 

" Stimson, L. A. : "Fractures and Dislocations," 1900, third edition, page 463. 

** Kronlein : Deutsche Chirurgie, XXVI, page 82. 

** Bradford and Lovett : "Orthopedic Surgery," New York, 1905, third edition, 
page 479- 

"Bartels: Archir. f. klin. Chir,, 1874, XVI, page 643. Through Stimson. 

•• Pungaud : "Diet. Encycloped. des Sc. Med.," page 606. Through Stimson. 

" Drer>khahn : Zeitschr. f. orthop, Chir., 1903, II. Through Blumenthal. 

" Joachimstal : Die angeborenen Verbildungen der obern Extremitdten, 1900, 
Seite 17. Through Blumenthal. 

* Kiimmell : Die Missbildungen der Extremitdten, Biblioth. med., Band. III. 
Through Blumenthal. 

**Drenkhahn: Deut. milit'drdrstl. Zeitschr., 1905, Heft 6. Abstract Deut. med. 
IVochenschr., 1905, July 6. 

** Discussion of Powers* paper. 

** Quoted by E. M. Moore, in "Reference Handbook of the Medical Sciences," 
Philadelphia, 1886, II, page 485. 

" Riss, Raymond : "Die angelborene Luxation des Radius, Franzosische Disser- 
tationen," Paris, 1902. Abstract in Centraiblatt f. Gynak., 1903, 38, page 
1 150. 

" Hamilton S : "Case of Congenital Synostosis of Both Upper Radio-Uluar Ar- 
ticulations," British Medical Journal, November 18, 1905, Number 2342, 
page 1327. 



CONDUCT OF LABOR DURING THE SECOND STAGE.* 

By WILLIAM H. .MORLEV, Ph. B.. .M. D., Ann Arbor, Michigan. 

DBMONSntATOK OF OBSTBTRICS AND GVNBCOLOGV IN THB UNIVBRSITY OF MICHIGAN 

An apology is due to members of the Society for bringing this 
hackneyed subject to your notice, but my recent experience and the 
vast amount of material at my command during two years abroad may 
to some extent mitigate my extreme audacity in presenting this theme 
for your consideration. 

It is needless to tell you, but nevertheless important to define at the 
outset the various stages of labor. Labor is arbitrarily, and for matter 
of convenience, divided into three stages. The first dates from the 
time the parturient commences to have labor pains until the cervix 

♦Read before the Washten.aw County (Ann Arbor) Medical Society. 



114 ORIGINAL ARTICLES. 

is fully dilated. This condition of full dilatation is determined when 
the patient begins to bear down. The second stage extends from full 
dilatation of the os to birth of the child, and the third and last stage 
from delivery of the child until the birth of the placenta and mem- 
branes. In the first stage the pains may be so severe as to compel the 
parturient to take her bed, but as a rule she is up and about. She 
should, however, be put to bed soon after the membranes rupture, or 
at the beginning of the bearing-down pains. This is especially impor- 
tant in multipara as the second stage is usually of short duration ; often 
lasting but five or ten minutes from complete dilatation of the cervix 
to birth of the fetus. 

I take it for granted that you have had your patient under sur- 
veillance for some months previous to the beginning of the first stage, 
and have made all necessary arrangements for the confinement. The 
external examination, diagnosis of presentation and position, clipping 
of vulval hair, aseptic preparation of external genitalia, dressings, 
et cetera, have all been made. As the second stage is short in multipara, 
it is well during the first stage to have the bed in readiness for recep- 
tion of the parturient, and it is about its preparation that I wish next 
to speak. 

Preparation of the Bed, — ^A high iron bed is the best, but as often 
occurs in private practice, the physician may be compelled to use the 
low double bed. In either case its preparation is the same. The 
accoucheur stands, or is seated at the left side. This fact should be 
borne in mind when the bed and accessories are made ready for the 
confinement. A rubber sheet of sufficient length and width should be 
placed to cover the entire mattress. Over this an ordinary sheet. 
Then a second rubber sheet of sufficient size to cover the middle third 
of the bed and on top of this latter another sheet. These two latter, 
that is, the rubber and the muslin sheet, should be so arranged as to 
allow easy removal after completement of the third stage. The puer- 
peral patient will then recline upon the large rubber and muslin sheet 
mentioned above. In the bed thus prepared with its double layer of 
rubber and muslin sheets, the parturient is placed, preferably on her 
left side. Underneath her buttocks, which are brought as far as pos- 
sible to the left edge of the bed, may be placed a Kelly pad, with the 
apron extending over the edge into a bucket or pan, or what I per- 
sonally prefer, a sterile pad of gauze and cotton placed under the 
buttocks to receive whatever discharge may come from the vulva 
during the second stage. To prevent contamination from the hips of 
the patient, l^gings, which have been previously sterilized, are drawn 
on and tied high up on the hips. The buttocks are covered with a 
sterile sheet, and another is placed on the bed in front of the posterior 
buttock. 

Examination During the Second Stage. — ^Vaginal examinations, 
except in rare cases, are to be condemned. External abdominal exam- 
ination between pains to denote progress in descent, or the extent of 



LABOR DURING SECOND STAGE. 116 



i 



engagement of fetal head, can be made as often as. necessary. I 

Control of fetal activity by auscultation of fetal heart from time to 
time is also a good procedure. But constant and repeated vaginal 
examinations cannot be too strongly deprecated. The great risk of 
.infection, and the small amount of additional information to be gained, 
do not, in most cases, warrant such a drastic procedure. 

Delivery. — When the vulva begins to gape or the perineum com- 
mences to bulge, it is time for the accoucheur to disinfect his hands 
and arms with soap and water, and then with bichloride. A long-sleeved ' 
gown and rubber gloves, both previously sterilized, are put on. Then 
the sterile sheet is placed over the buttocks, and another on the bed in 
front of the posterior buttock. It is seen that the parturient is on her 
side, preferably the left, in a modified Sims position with her buttocks 
near the left side of the bed. On a table near-by covered with a sterile 
sheet are placed two sterile basins, one containing sterile water, and one 
bichloride (one to two thousand). In both solutions are placed small 
pledgets of sterile cotton. The table should also contain a basin with 
tape for cord, scissors, and a catheter, all of which have been previously 
sterilized. Instruments for perineal repair, obstetrical forceps, et cetera, 
are boiled and kept in readiness. A blanket, or preferably a padded 
box, over which a sterile bag with purse string suture is drawn, is put 
between the knees of the patient. The left hand of the physician is 
placed between the thighs of the parturient and brought around in such 
a way as to cover the vulva. The right hand is free to wipe away 
fecal matter discharged from the rectum with the pledgets of cotton 
soaked in bichloride or sterile water, and to protect the perineum 
during the pains. In this way the accoucheur has the fetal head and 
perineum under complete control. 

Use of an Anesthetic. — The question naturally arises, shall an anes- 
thetic be employed ? In few cases, confinement may take place without 
anesthesia. It is better both for mother and child not to administer 
an anesthetic during the first stage. It often becomes necessary, how- 
ever, in the second stage to give the parturient a few whiffs of chloro- 
form to ease the pain, and at the same time save the perineum. Do 
not slug your patients with chloroform. It is not necessary. It will 
often unnecessarily prolong labor, and prevent later contractions of the 
uterus. When a pain starts a few drops of chloroform on an Esmarch 
inhaler will prove sufficient, and the cone should be removed at the 
completion of the pain. A small amount of the anesthetic given 
synchronous with pains will have the desired effect. There is little to 
be said in the choice of an anesthetic. Qiloroform has, since its 
discovery in 1847, by Sir James Simpson, been considered the ideal 
lying-in-room anesthetic. Recent investigations with cocaine injected 
intraspinously, with scopolamine, and other local anesthetics, have 
shown some good results, and much is claimed by their adherents. 
The results are too meager, however, to allow them to supplant chloro- 
form. 



116 ORIGINAL ARTICLES. 

Protection of the Perineum, — As was mentioned above, the par- 
turient is placed on her left side in a semiprone, or a modified Sims 
position, with her buttocks near the left edge of the bed. The thighs 
are held apart with the padded box, over which a sterile bag has been 
drawn. The obstetrician stands with his left side against the edge 
of the bed. His left arm is put around between the thighs, so that 
the left hand may easily cover the vulva and control the fetal head. 
The right hand is free to protect the perineum, and keep the parts 
cleanly and aseptic with the pledgets of cotton, dipped alternately in 
sterile water and bichloride solution. At the commencement of a 
pain the left hand allows the head to slowly advance upon the already 
somewhat distended perineum. The right hand, upon whose palmar 
surface is placed a pledget of cotton wet with bichloride, is so placed 
that the thumb and first finger span the fourchette. The perineum 
is grasped on either side and slightly folded. As the head advances, 
controlled by the left hand, the perineum is allowed to gradually receive 
the force of the advancing head, so that before completion of the pain 
the perineum has received the full impact of the head as rapidly or as 
slowly as the physician desires. This can be repeated until it is thought 
the perineum is fully dilated. I have by this method held the head 
back with my left hand, when removal would have allowed the head 
to slip over the perineum, which I did not deem fully stretched. When, 
however, the perineum is fully dilated and extension has taken place 
to such a degree that the forehead is visible at the fourchette, the 
tension of the left hand between a pain be gradually relieved, and 
birth of the head is allowed to take place. This is done in the follow- 
ing way : the occiput is well out from under the arch of the pubes, and 
the left hand gradually brings about increased extension of the head 
by light traction on the brow. The right hand, whose thumb and 
forefinger rim the fourchette, presses lightly but firmly on the perineum 
and follows it down over the brow, face, and chin. External rotation, 
or restitution, immediately takes place. 

Cord About the Neck. — Examination is at once made to see if the 
cord is about the neck. When such is the case it is at once reduced 
by slight traction, and slipped over the head. It may be necessary to 
clamp the cord when reduction is impossible. But these are rare 
instances, as it is only in cases where the cord is unusually long that 
it becomes wound around the neck, and from its increased length is 
easily reducible. 

Delivery of Shoulders, — As soon as the head is born the patient is 
placed in the dorsal position. The head is grasped with both hands in 
such a way that the palmar surfaces lie next to the lateral surfaces 
of the head, and just anterior to the parietal bones. Slight pressure 
is made downward and backward, until the anterior shoulder appears 
well out from under the arch of the pubes. The head is then lifted 
upward to allow the posterior shoulder to glide over the perineum. 
Delivery of the body usually follows rapidly, but to prevent tear of 



LABOR DURING SECOND STAGE. 117 

the perineum the hands should still be kept on the head. In addition 
the forefingers are lightly inserted in the child's axillae, and tjhe fetus 
carried upward and forward over the mother's abdomen. In this way 
the child follows the curve of Carus and its weight is not allowed to 
tear the already greatly distended perineum. Care should be taken 
not to use traction with the forefingers which have been placed in the 
child's axillae. Stretching of the brachial plexus, or fracture of an 
arm may result. The tension should be on the head, but to prevent 
too great tension and the slipping of the hands from the head, the 
forefingers are placed in the axillae. • 

Ligation of the Cord. — The child is held upward by the lower limbs 
and a parental slap made on the buttock to expel any mucus that 
may lodge in the posterior pharynx and upper respiratory passages. 
A vigorous lusty cry will denote that the trachea is clear. The child 
is then placed on its right side close enough to the mother to prevent 
traction on the cord. The cord is grasped and pulsation controlled. 
As long, as the cord pulsates, it is not tied. When pulsation stops, a 
narrow tape is passed around the cord about seven centimeters from 
the child's body, and securely tied. Another is similarly placed, and 
the cord ligated on the maternal side about three centimeters from the 
first ligation. The cord is then laid in the palmar surface of the left 
hand in such a way that the hand is interposed between the child's 
abdomen and the ligatures. The cord is cut, all bleeding stopped, and 
the child handed to the nurse. 

A bed pan is placed under the patient's hips for reception of the 
after-birth. The uterus is held by the hand of an assistant or nurse 
to prevent its relaxation, and the third stage begins. 

Use of Ergot. — So much has been written about the use of ergot 
in the second stage, or at its completion, that I cannot refrain from 
saying a few words on this point. Such a practice need only be men- 
tioned to be most severely condemned. First, it is never indicated, as 
slight massage of the fundus uteri will control any slight hemorrhage 
in most cases. In uncontrollable hemorrhage, first remove the after- 
birth by Crede's method, then give your ergot. Secondly, ergot 
administered in the second stage will cause the uterus to contract 
down upon the placenta and membranes, and cause their retention, 
whole, or in part. I never prescribe ergot in the third stage unless 
indicated, and am not a firm believer in its employment as a prophy- 
lactic. 

Repair of Perineum. — This properly belongs to the third stage, but, 
should a tear occur, it may be well to pass the silkwormgut sutures at 
the end of the second stage before the patient comes out from under 
the anesthesia. The ends can be held with hemostats and tied after 
the placenta and membranes are born. This does away with a second 
anesthetic. Personally I prefer to let patient out and then repair any 
tear at end of the third stage. A few whiflFs of chloroform are gen- 
erallv sufficient. 



118 ORIGINAL ARTICLES. 

Such in brief is the method I have adopted in the conduct of labor 
in the second stage. I do not claim any originality, do not believe I 
have invented anything new. Having seen a good many different 
obstetricians, and studied their methods, I have only taken what I 
considered to be their best points to form one of my own. This I 
have endeavored to bring to your notice this evening. Just one point 
more ; do not forget that labor in most cases is a normal, physiological 
process, and any unnecessary meddling may transfer it from the 
domain of physiology to the realms of pathology. DO NOT DO IT! 



REMARKS ON LA GRIPPE. 
By JOHN S. CAULKINS, M.D., Thornville, Michigan. 

Personal subjection to la grippe affords the most certain means of 
obtaining a complete and intimate knowledge of the nature and results 
of the disease, but the writer has not l^een permitted the opportunity 
of study from the standpoint of patient, and can therefore only record 
what has been observed in practice. 

Description of the Disease. — It is difficult to classify Russian influ- 
enza under any name that will imply the nature of the disease. The 
nearest approach possible is to call it a catarrhal fever, but that scarcely 
covers the ground, for many cases — perhaps a third of the total — show 
very slight catarrhal symptoms. We might almost say there are two 
distinct forms of la grippe — the catarrhal and the noncatarrhal. In the 
first there is cough, congestion of the mucous membranes of the lungs, 
throat and head, together with all the symptoms of a severe cold. The 
other is a break-bone fever without the catarrh. The two have some 
features in common, the fever in both being high, and the pain in head 
and back, between^the hips, intense. 

Tliermometry of the Disease. — Perhaps there is no other affection 
in which the fever runs higher, not excepting malignant scarlet fever. 
It is a scorching, burning fever. It is not so high now as formerly, 
when it was common to record 104°, in cases of vigorous, strong boys 
105° being noted, and in a few instances even registering above that 
high point. However, seldom will much more than 103° be observed. 
No low temperatures were found by me in typical unmixed cases, and 
r think there are none, although this statement may be criticized in the 
discussion of this paper. Some may say, perhaps all may unite in 
saying, that, any grade of fever may characterize the malady, but I 
have expressed my belief, and when every source of error is eliminated 
I think the statement will be found correct. An epidemic of gigantic 
proportions necessarily contemplates a great number of other diseases, 
among which may be mentioned common influenza, which is always 
endemic if not epidemic, and can only be discriminated from la grippe 
by its milder type, the temperature being low. Here would be one, 
and possibly the main, source of error. Another would lie in not 
accurately observing the dividing line between the temperatures of la 



REMARKS ON LA GRIPPE. 119 

grippe and its numerous sequels. What renders my opinion probable 
is the fact that every disease has its own thermometry from which it 
does not vary much. This point is sometimes invaluable in differential 
diagnosis. Who ever saw a low temperature in measles or scarlet 
fever, or a very high one in rotheln? 

Duration of the Disease, — La grippe, according to my observation, 
lasts three days. If the attack has its inception on Monday morning 
the patient will be free from fever on Thursday morning. Of course 
I do not include relapses or sequels. These are not la grippe, they are 
conditions that succeed it. 

Complications, Relapses and Sequels, — Pneumonia has not been 
observed as a complication by me, but it has been met as a sequel. 
Bronchitis is a frequent complication, so are congestion of the lungs 
and tonsillitis. It is doubtful if there is any real relapse of la grippe. 
I should as soon look for a relapse of measles. The sequels of the 
disease are many, some immediate and some remote. The immediate 
in the order of gravity are pneumonia, nervous prostration, bronchitis, 
and neuralgia. Among the remote, consumption has caused death in 
some who had la grippe two years previously. In another class of 
cases the mischief that was done by la grippe can only be described by 
saying that the constitutions of the subjects were wrecked by the 
disease. 

Tlie Cause. — For hundreds of years there has been great speculation 
over the cause of this disease. Influenza is an Italian word that has 
been used in the English language until it is naturalized and means 
simply influence. The influence of what? When the world believed 
in astrology, it was thought to be rained down by certain malign stars 
in conjunction or apposition, or whatever the phraseology. That 
superstition outgrown, it was believed to be caused by some occult 
telluric influence. This idea has been promulgated in my time not 
only with regard to influenza but Asiatic cholera as well. The Germans 
adopted the name for the disease. They called it the Nordische or 
Russiche influentz. The belief in an influence was natural enough at 
that time. The spectacle of so many falling sick at once, suggested 
the idea of the disease being sent by some power inimical to the human 
race. The French name suggested something akin to the same idea; 
as if some invisible monster had suddenly grasped its helpless victim 
in its talons. 

La grippe is an essential fever, and like the rest of its class can have 
but one way of spreading, and that is by the reception into the circula- 
tion of its own contagium virum, the living microbe or fungus, which 
causes the sharp and active fermentation in the blood, so characteristic 
of the disease. It would be more correct to say, which is the disease. 
The ptomaines generated during this fermentation must be peculiarly 
poisonous, for the extreme prostration, lassitude and pain which mark 
the disease are out of all relative proportion to the catarrhal symptoms 
and must be caused by these poisons. The microbe of la grippe is not 



120 ORIGINAL ARTICLES. 

yet identified, or at least observers who claim to have discovered it do 
not agree in its description. Pfeiffer, the son-in-law of Koch, is the 
latest claimant, and the confirmation of his alleged discovery is looked 
for with interest, but if his claim is not confirmed, nor even that of any 
other observer, we may rest assured that the microbe is in waiting to 
be discovered. 

Pfeiflfer is connected with the Berlin Institute for Contagious Dis- 
eases. His conclusions are based on a careful study of thirty-one 
cases of la grippe, six of them being postmortems. His microbe is a 
minute rod or bacillus as thick as that of mouse septicemia and half as 
long. There is some difficulty about culture and staining, and this has 
misled other observers. PfeiflFer believes that other observers have 
seen the same bacillus but have described it as a micrococcus because 
it takes the stain at the ends. Kitasato has seen and described the 
bacillus, agreeing essentially with Pfeiffer. The microbic and con- 
tagious nature of the disease is admitted, but some work is needed to 
learn just how the contagium virum is conveyed from one to another. 
In all probability it is in the breath of the patient, and perhaps in the 
secretion of the skin. 

Treatment, — More than three-quarters of the cases of la grippe are 
treated at home in a variety of ways. A favorite method of treatment 
is to take a dose of pills and^drink all the cider, made strong with red 
pepper, one can hold. The other quarter, or less, that the doctor sees 
are mostly complications and sequels and are to be treated symptomat- 
ically. There is no specific for the disease. It is a good plan, if the 
person is seen during the attack, to give a cathartic — say a dose of 
compound cathartic pills. The operation will materially relieve the 
intense pain in the head, and awaiting that, a dose or two of acetanilid 
will afford much relief. We ought, however, to select our cases for 
this treatment. The effect is too depressant sometimes for safety. 
Now and then a patient will sweat so profusely that it is really alarm- 
ing. We should be very careful with acetanilid in la grippe. Still, I 
have given it to small children and once to a man eighty-two years of 
age, with excellent effect. Antipyrine. which was so extensively used 
two years ago, seems to have dropped out of focus. Beyond a doubt 
much harm has been done with that drug. That class of remedies, in 
such a prostrating disease as la grippe, ought to be used with great 
caution. After the bowels are evacuated opiates are to be preferred to 
them if the pain in head and back continues. Quinine is not a specific 
in la grippe. It neither shortens its course nor does it afford any -relief 
so far as 1 have observed. 

Notwithstanding treatment the malady has its course to run and the 
function of the doctor is to see that the course runs normally and to 
obviate, if possible, any threatened mischief. Avoidance of all exposure 
for a week after the disease subsides is of the utmost benefit to the 
patient. It -is carelessness in this particular that makes work for the 
doctor. 



WASHTENAW COUNTY MEDICAL SOCIETY. 121 

TRANSACTIONS. 



WASHTENAW COUNTY MEDICAL SOCIETY. 



REGULAR MEETING, ANN ARBOR, DECEMBER 14. iQ^S- 
The President, JOHN A. WESSINGER. M. D.. in the Chair. 
Reported by JOHN WILLIAM KEATING. M. D.. Secretary. 

REPORTS OF CASES. 
AN UNUSUAL CASE OF DYSMENORRHEA. 

Doctor James B. Wallace: A single lady, aged twenty-one 
years, living at home, came to me March 18, 1905, complaining of 
severe attacks of dysmenorrhea. She is the second daughter in a family 
of four girls. Her mother, now aged forty-five, w-as troubled with 
severe menstrual pains when a girl and attributed the patient's affection 
to an hereditary influence. The patient's sisters have no more pain at 
the menstrual periods than is considered normal. The jnother is a 
healthy woman and her confinements were normal and easy. The 
family are all in good health except the patient, and she has never 
experienced any trouble except at the menstrual periods, and the fact 
that she is subject to a very obstinate constipation. 

The patient has had the ordinary diseases of childhood, and no 
other sickness nor disease. She was regarded to be perfectly well up 
to the age when she would ordinarily begin to menstruate. About the 
time she was thirteen or fourteen years of age her mother noticed that 
she was nervous and feverish, and oftentimes choreic. This she attrib- 
uted to the approaching catamenia and did not pay much attention to it. 
The nervous disturbances did not disappear although the mother thinks 
they did not increase as time went on. Menstruation was not estab- 
lished, however, until the patient was seventeen years old, and at that 
time she was almost in convulsions from the pain. The girl had no 
medical treatment during the years of approaching maturity, except 
some patent nerve nostrum, Lydia Pinkham's vegetable compound, and 
Porter's pain king. 

After the menstrual function was established, the patient felt better, 
except a few days before and during the menstrual week. Her nervous- 
ness and apprehension did not abate, but she began to await the dreaded 
period with feelings approaching hysteria. The pain just before the 
flow began was so severe that for a few months before the patient came 
under my observation, she had gone into convulsions at those times. 
She was quite irregular, sometimes going seven to eight weeks, and at 
other times menstruating as often as every two or three weeks. 

The period in February, 1905, was the worst she ever had, and the 
mother told me that she had much more severe pain than any woman 
she had ever seen in labor. The reason she had never had treatment 
for her trouble was an implicit faith in patent medicines on the part of 



122 ORIGINAL ARTICLES. 

her mother and a somewhat exaggerated dread of exposure on her part. 
On March i8, 1905, the mother came to consult me about her but 
dtd not bring the patient along. I obtained the facts of this history as 
I have given them, from her at that time. I plainly told the mother 
that she must bring the patient and be prepared to have her examined 
if need be, before I could tell her the cause of her trouble. Several 
days later they came to my office. The girl was a well-nourished, and 
healthy-looking lass, and did not show the signs of the nervous disturb- 
ances through which she had gone. A careful and extended physical 
examination showed that there was nothing wrong with any of the 
organs of the body except the site of the trouble, plus the chronic consti- 
pation, and a peculiar drawing or bearing down feeling during the act 
of defecation and sometimes also while passing urine. I then told the 
mother that unquestionably there was some abnormal position of the 
uterus and that I would make an examination. The patient consented 
and the cause of her trouble was soon apparent. The nymphae were 
very long but as the girl was scrupulously cleanly there were no irri- 
tants IcKjged there. The hymen was normal but very tight, and I found 
much difficulty to introduce the finger even through the hymen without 
producing much pain. Finally this was eccomplished and I found the 
vagina apparently smaller than the hymen. It appeared so small that 
I had to abandon the use of the finger and make exploration with the 
sound. The vagina was of normal depth and I could easily touch the 
OS uteri with the sound. While attempting to withdraw the sound 
I observed that the point caught upon something which I could not 
make out. Examination per rectum showed a retroflexion of the third 
degree. A speculum could not be introduced into the vagina so I 
tried a branching ear speculum which showed the cause of the trouble. 
Just inside the hymen was a septum extending from the anterior to the 
posterior wall, the whole length of the vagina and dividing it longitu- 
dinally into two nearly equal parts. I advised its immediate removal. 
This was agreed to, but the girl would not permit my bringing another 
physician to give the anesthetic. The next day I went to the patient's 
home, where I made ready, gave the anesthetic, and dilated the vagina. 
I found that the os uteri was freely movable ; a sound could be passed 
into it from either passage. The unusual part of this case consisted 
in the part of the septum near the os uteri. For about one inch in 
length, there was a wedge-shaped portion, — the base impinging against 
the OS — the apex becoming continuous with the membranous septum. 
This wedge-shaped portion was firm and contained muscular tissue. 
I removed the septum, controlling the hemorrhage with spray of adre- 
nalin; sewed up the wounds with chromacized catgut; replaced the 
retroverted uterus: packed the vagina with gauze; catheterized the 
bladder, and permitted the patient to come out from the anesthetic. 
When awake she said she had no pain and felt all right. I called again 
that night and there was no pain. 

Patient recovered without suffering any inconvenience, her bowels 



CLINICAL SOCIETY. 128 

became regular, and on the morning of the ninth day afterward she 
called her mother in alarm saying that the wound must have started to 
bleed. The mother telephoned for me and I went out and found that 
her period had come on anB she had begun to menstruate freely and 
without a trace of pain for the first time in her life. That was in 
March. Since then she has menstruated rcgularjy and has never had a 
symptom of pain. The uterus has stayed in normal position and she 

I has no more need for the nostrums she formerly imbibed. 

That wedge-shaped septum formed a cup-pessary which tilted the 
uterus backw^ard, and when the organ became turgent and distended" 
with blood at the period, occluded the os, producing the pain and con- 

I vulsions until the flux forced itself past the obstruction. 

i The girl is strong and well and is not so much afraid of doctors ; 

the mother is pleased, and has lost a very large part of her confidence in 
patent medicines. 



CLINICAL SOCIETY OF THE NEW YORK POLYCLINIC. 



STATED MEETING, FEBRUARY 5, 1906. 

The President, JOHN J. MacPHEE. M. D., in the Chair. 
Reported by FREDERICK C. KELLER, M. D., Secretary. 

READING OF PAPERS. 
ACUTE PELVIC INFECTIONS, 



I Doctor Joseph C. Taylor read a paper on the above subject. He 

said, in part : It is but a few years since a woman's tubes and ovaries 
were sacrificed by an operator lest a future laparotomy should be 
required. Actuated by a sense of thoroughness, he deprived women 
of the function of menstruation, which is interwoven with their mental 
as well as physical life. It is better to conserve these organs, even if 
elaborate and hazardous procedures must be adopted to accomplish this 
end as well as to cure the patient. He did not advocate, however, the 
carrying of conservatism in connection with special organs so far as 
to endanger the constitutional condition of women. There is a broader 
conservatism, which seeks to restore the general health of the patient, 
even if special organs must be sacrificed to attain such an end. To 
this end he made an appeal for early surgical interference in acute 
diseases of the female organs. Conservative operations sometimes 
may fail ; but even if they do, radical procedures must be adopted later 
without added risk to the patient. On the other hand, it is impossible 
to restore organs removed by radical work. 

For many years it has been customary in most large hospitals to 
treat patients suflfering from extension of gonorrheal inflammation to 
the tubes by hot antiseptic douches or perhaps by tampons and an ice- 



124 ORIGINAL ARTICLES. 

bag externally over the lower abdominal region. When the acuteness 
of the attack had somewhat subsided the tubes as well as the ovaries 
were frequently swollen and engorged to such an extent as to be desig- 
nated as tumors and removal was advised ; whereas, without apparent 
mutilation, the inflammation might have been checked in the beginning 
and the woman allowed to keep her organs, though somewhat damaged. 
The conservative work to be attempted is mainly that of evacuating 
the free pus in the culdesac when the operator is convinced by the 
bulging of the wall of the posterior fornix that purulent exudate is 
present in abundance. The gonococci, in an active state, after they 
have gained entrance into the uterine cavity, cause a destruction of 
the superficial cells, work their way into the deeper layers, and are the 
cause of an immense amount of purulent exudate, destruction and 
infiltration of the outer layers and edema of the deeper structures. 
Unfortunately, after gonorrhea has once become well established within 
the uterus, it invades by continuity of tissue the Fallopian tubes. The 
inner surface of the uterus may become such an active seat of inflam; 
mation in its deeper layers that the walls of the smaller vessels become 
involved, as do the surrounding lympathics, and the normal structure 
is almost entirely destroyed. The walls of the uterine cavity thus 
become suppurating surfaces, which later become sclerotic, and this is 
followed by a shrinking of the organ. This is frequently the case in 
mixed infections. 

If the tubes are opened and drained during the onset of the disease, 
the woman may retain her organs, though somewhat damaged. The 
operation is very simple, but it necessitates a thorough knowledge of 
female pelvic anatomy and careful manipulation of special instruments. 
An incision is made on the posterior surface of the cervix at the junc- 
ture of the vaginal mucous membrane with the cervical, care being 
taken to keep close to the cervix. A ^air of blunt-pointed scissors, 
curved on the flat, seems best adapted for this purpose. When the 
incision is made in the curve of the fornix, a painful scar is apt to 
result, the nearer the rectum is approached the greater being the sensory 
nerve supply. After incising the mucous membrane and retracting the 
divided edges, a small amount of loose alveolar tissue is encountered 
(most marked in women after the menopause). After incising this the 
peritoneum is easily divided or punctured. With the forefingers the 
opening can be enlarged. The uterosacral ligaments being pushed 
outward by the palmar surfaces of the fingers and the intestines carried 
out of the way by means of the Trendelenberg position and held there 
by pads, the tubes are easily brought into view by means of the proper 
instruments for retraction. If this procedure is adopted in the very 
early stages, as it should be, the tube will be found reddened, swollen, 
and with a tendency to sink into the culdesac. It should be grasped 
with a pair of blunt forceps, such as those of the modified Hunter type, 
on the dorsal surface, and pulled into the opening. It should be remem- 
bered that the tube, like the ovary, except at its uterine extremity, is 



CLINICAL SOCIETY. 125 

fed by small ascending branches from the ovarian artery, which enter 
the structure from the lower surface; consequently, when an incision 
is made it should be on the opposite side. Care should be taken to 
keep the intestines out of the way by means of pads, the tubes being 
incised along the outer two-thirds of the upper border. The contents 
should then be evacuated and the entire surface thoroughly swabbed 
with five-per-cent iodoform gauze. At first there will be considerable 
oozing of blood, which gradually subsides, no main vessel having been 
cut. A small strip of iodoform gauze should then be placed over the 
raw surface, an end protruding into the vagina. The first eflFect of 
this treatment is to reduce the interstitial cellular infiltration, as it is 
a well-known fact that the gonococcus does not thrive well on exposed 
surfaces, its natural abode being in the deep recesses of compound 
racemose glands. The gauze may be removed from the culdesac in 
from five to six days. This may be done with safety after such a 
period, as the life of the gonococcus at best is very short, except in 
racemose glands and closed sacs. 

REPORTS OF* CASES. 

FRACTURE OF THE ULNA DURING MASSAGE FOLLOWING OPERATION 
FOR COLLESr FRACTURE. 

Doctor Frederick C. Keller : I wish to show this patient. After 
the removal of the splint her arm was being massaged when the ulna 
snapped at a point several inches above the original site of fracture. 
This occurred six or eight weeks after the operation, and could be 
attributed only to some inherent disease of the bone. 

DISCUSSION. 

Doctor Joseph C. Robertson : I have put up from two hundred 
to three hundred cases of Colles' fractures during the past eight years, 
and until two years ago have applied a posterior splint, the arm being 
semiflexed in a stiflf position. This gave far from perfect results in 
eight out of ten cases. A careful study of these cases has convinced 
me that the best results are obtained by applying a posterior splint 
from the hand to the elbow, keeping the arm perfectly straight, and 
putting a pad of cotton under the wrist. As a result there is no sharp 
protrusion of the ulna at the elbow, as often occurs when the hand is 
put up anteflexed. 

Doctor John A. Bodine: Something was wrong with the com- 
position of the bones of this patient, as ulnas do not snap from massage. 
The bones were probably chalky. As to Doctor Robertson's experience 
with Colles' fractures, I think that each surgeon favors the line of 
treatment with which he, personally, has obtained the best results. I 
think a posterior splint more practical, for the reason that the posterior 
surface of the arm is a straight surface, and has no cutaneous nerves 
and no return blood supply. If a rigid anterior splint is applied to the 
front of the arm, edema is caused by obstruction of the circulation. 



126 ORIGINAL ARTICLES 

INTUSSUSCEPTION. 

Doctor Alexander Lyle: I desire to report a case of intussus- 
ception occurring in a child seven and one-half months old. The 
patient, well-nourished, healthy, active and breast-fed, had enjoyed 
perfect health, with the exception of constipation, until the evening of 
December i8, 1905, when he was suddenly seized with severe abdominal 
pain, as evidenced by crying and flexion of the thighs upon the abdomen. 
He was given a hot mustard footbath, and, internally, hot water with 
gin and paregoric. His bowels had moved normally on the preceding 
day, but not on the day of the attack. At i a. m. the child passed about 
half an ounce of bloody mucus but no fecal matter. Pain was severe 
and recurrent in character and at 6 a. m. on the 19th a physician was 
summoned. He ordered half an ounce of castor oil. This failed to 
produce an evacuation of the bowels. On the evening of the 19th he 
ordered an enema (rectal) of glycerine and hot water. During the 
night the mother noticed a sudden change in the child's condition and 
thought it to be dying. She could not reach the physician, and in the 
morning I was summoned. On reaching the house I found that the 
physician had arrived and had given an enema of an ounce of castor 
oil and one pint of warm water, the water returning with bloody mucus. 

Hasty examination showed a state of collapse, a weak pulse that 
could not be counted, a tense, rigid abdomen, and a rectal temperature 
of 103° Fahienheit. A diagnosis of intussusception was made and 
immediate operation advised as offering the only hope (and that a poor 
one.) 

' The child was immediately brought to the Polyclinic Hospital and 
operated upon. No tumor could be mapped out, even after he had 
been anesthetized. An incision was made in the right rectus muscle, 
just below the umbilicus, the abdominal contents examined and' intus- 
susception located in the ileocecal region. A firm, dense band of 
adhesion anchored this portion of the intestine, necessitating a con- 
siderable amount of work before it could be brought into the wound. 
This was finally accomplished and the intussusception reduced. The 
gut was not gangrenous and therefore was returned to the abdominal 
cavity. A loop of small intestine w^as picked up and two drams of 
saturated solution of magnesiurn sulphate was thrown into it by means 
of a syringe, the needle of which was carried obliquely into the lumen, 
the object being to evacuate the bowels as soon as possible. The 
abdominal wound was then closed. 

Following the operation the child's temperature rose to 103.5° 
Fahrenheit, and remained so until i a. m. of the next day, when it 
dropped gradually to 99.5° Fahrenheit, and did not rise above 100.8° 
Fahrenheit at any time afterward. The pulse could not be counted 
until the temperature had fallen to 101.8° Fahrenheit, when it was 160, 
later falling to 118 or 120. The bowels moved five times during the 
first twenty-four hours after the operation. 



CLINICAL SOCIETY. 127 

I would emphasize the point that valuable time must not be lost by 
useless, or, more properly speaking, positively injurious and dangerous 
medication. The sudden abdominal pain, followed by a discharge of 
bloody mucus from the rectum, the recurrent attacks of pain and 
absence of fecal exacuations indicate immediate operation. Gangrene 
or extensive adhesions, or both, are produced by delay, and an intes- 
tinal resection and circular enterorrhaphy will be necessary. An early 
operation, on the contrary, enables the surgeon to early effect reduction. 

DISCUSSION. 

Doctor Bodine : One point should be emphasized in the diagnosis 
of an inflammatory abdominal condition in a child, and that is the 
expression of the face, which is always typical. Another aid is the 
abdominal pain. I think it would have been impossible to have made 
a differential diagnosis between this condition and appendicitis if it 
had not been for the presence of the bloody mucus. 

Doctor Maurice Packard : In cases of abdominal lesions in chil- 
dren up to three years of age, the differential diagnosis between intus- 
susception and strangulated hernia usually has to be made. The only 
point in diagnosis especially pointing to intussusception is the bloody 
mucus. A body temperature of 103° Fahrenheit, and a rapid pulse 
are also significant, as the statement is made in many text-books that, 
except in appendicitis and general peritonitis, the temperature and pulse 
are normal and the abdomen relaxed. It has been my experience that 
in intussusception children always have a high temperature and have 
a pulse so rapid that it is almost impossible to count it. In cases of 
intestinal obstruction the absence of stools and gas assists one in making 
a differential diagnosis, as in intussusception only mucous and blood 
pass from the bowels. 

LARGE OVAR/AX CyS7\ 

Doctor Charles G. Child, Jr. : I removed this cyst from a patient 
thirty-eight years of age. She has complained of pain for four or five 
years, during which time she noticed the presence of a tumor, which 
grew progressively larger. Examination revealed an enlargement 
reaching to the umbilicus. It was impossible to palpate the appen- 
dages on either side, and it was also impossible to determine on which 
side the tumor originated. On account of the pain being on the right 
side it was concluded that the tumor was of the right ovary, but at 
the time of operation it was found to involve the ovary on the left side 
and to have rotated the uterus. It firmly compressed the appendages 
on the right side, which accounted for the pain on that side. A 
transverse incision showed the cyst to be inherent in all directions to 
the omentum and posterior peritoneum. A portion of it was free from 
adhesions, and at this point the fluid contents were aspirated. The 



128 ORIGINAL ABSTRACTS. 

sac was then pulled out, with the intestines and omentum, and the 
adhesions separated. The sac contained a dark, water-like fluid, which 
is rather unusual, the contents of such a tumor usually being of a 
yellow straw color. 



ORIGINAL ABSTRACTS. 



MEDICINE. 

By GEORGE DOCK, A. M., M. D., D. Sc, Ann Arbor, Michigan. 

PKOriSSOK OP MWDICINB IN THE UKIVBRSITT OF MICHIGAN. 

AND 

DAVID MURRAY COWIE, M. D., Ann Arbor, Michigan. 

FIRST ASSISTANT IN MBDICINB IN THB UNIVERSITY OF MICHIGAN. 



THE RHYTHMIC SOUNDS OF THE ALIMENTARY CANAL. 

In a decidedly interesting description of a series of investigations into 
the causes of the various sounds produced in the gastroenteric canal, 
Cannon (Jama, January 20, 1906) concludes that stomach sounds are 
best heard over the pyloric ring at the tip of the eighth rib. These 
sounds are explosive in their character, loud, and correspond with the 
rhythmical contraction of the pylorus, they occur about once in every 
twenty seconds and are distinguished by auscultation with a stetho- 
scope. Small intestine sounds can be differentiated from those of the 
stomach and large intestine sounds by auscultation over the lower por- 
tion of the abdomen. These sounds are best heard when the stomach is 
empty, in the early morning, and particularly over the lower left 
quadrant; the object of this position is to get as far away from the 
active portion of the colon as possible. The sounds are soft, confused, 
rolling, rising and falling in intensity, not rattling and explosive like 
those of the stomach. They continue for four or five seconds, disap- 
pear, and return again at intervals of seven or eight seconds, and persist 
in the same location for indefinite periods of time. 

The sounds of the large intestine present no periodicity, are easily 
distinguished from the other sounds, and are heard over any portion of 
the active colon, the ascending and transverse portions. The sounds 
are very coarse and rumbling, with heavy gushes of gas from one seg- 
ment to another. The intervals are longer, from fifteen to forty-five 
seconds. 

The author used, as a method of eliminating the personal equation, 
a recording telephonic transmitter. The article should be read with 
care, as it is impossible to do justice to it in a brief review. The sounds 
are somewhat dependent upon the character of the food eaten, that is, 
certain sounds can be better differentiated if certain substances are 
eaten. d. m. c. 



TREATMENT OF FRACTURE. 129 



SURGERY. 



Bv FRANK BANGHART WALKER, Ph. B., M. D., Detroit. Michigan. 
rmowwMom op svmGBitT amd opbrativb surgbkt in the dbtkoit postgkaouatb school of MBDiaMi; 

ADJUNCT FKOPUaOK OP OPBBATIYB SUKCBKT IN THB DBTKOIT COLLBGB OP MBOiaNB. 

AND 

CYRENUS GARRITT DARLING, M. D., Ann Arbor, Michigan. 

CLINICAL PBOPBSaOK OP SUBOBBT IN THB VNIYBBSITT OP MICHIGAN. 



THE MODERN TREATMENT OF FRACTURE. 

Carl Beck, M. D., of New York (Medical Record, Volumel.XIX, 
Number XII). It is quite refreshing to read an article with the above 
title, in which the writer dares to advance new ideas and cut away from 
some of the traditions which have long interfered with the scientific 
treatment of fractures. 

The Roentgen ray has not only become a valuable aid in diagnosis, 
but compels much better resuhs in treatment. Injuries that were for- 
merly treated as dislocations, sprains, contusions or distortions are now 
known to be fractures, a glance through the fluoroscope revealing the 
true condition. 

Fractures without displacement, entering an articulation, may have 
considerable effusion. Without knowing the condition the surgeon 
would be strongly tempted to manipulate. A skiagraph would at once 
show the condition and suggest the line of treatment. The writer 
prefers a plaster-of-Paris dressing because it adapts itself to any part 
of the body and offers no obstacle to the Roentgen rays. 

The rules, that fragments must be reduced, and that, after proper 
position has been attained fixation is in order, while simple, are fre- 
quently violated. 

The dogma that the soft tissues are the most important part of the 
treatment of fractures, is dangerous. Repair must take place in the 
bone, while the soft parts may be injured by imperfect reduction. With 
perfect reduction joints and tendon-sheaths are at once set free and 
remain so, unless immobilized for a long time. 

A fracture is a wound in which union by first intention is desired ; 
accurate coaptation of parts is therefore necessary. What was for- 
merly regarded by many as bone callus was nothing but a displaced 
borie fragment. The only way to insure the exact reposition is by 
using the Roentgen ray. The practitioner must resort to this not only 
for the good of his patient but for his own protection. 

In old displacements of not more than two weeks standing refrac- 
ture may be successfully performed under anesthesia. Old fractures 
are to be opened and refractured with a thin broad chisel; in such 
cases when there is great tendency to displacement suturing with bronze 
wire is indicated. Periosteal shreds may become ossified and lead to 
deformity. When the bone is treated by open operation these should 
be carefully removed. 

The patella offers a good example for technique of operation. It 



130 ORIGINAL ABSTRACTS. 

has little tendency to osseous regeneration. Effusion following frac- 
ture tends to keep the fragments apart. Contraction of the muscles 
tends to keep them separated, and soft tissues interpose to fill the gap. 
The Roentgen ray shows that not in a single instance is reduction 
perfect even under anesthesia. The only rational remedy is to open 
the joint, remove the intervening structures, and accurately replace the 
suture with catgut or bronze wire, according to conditions. 

A number of histories are given to illustrate the points taken. The 
views which he holds are summarized as follows: 

( 1 ) The Roentgen method, in combination with the usual methods 
of examination, determines the character of the suspected bone injury. 

(2) If there be no bone injury, the proper treatment consists in 
massage, followed by immobilization, a movable splint being prefer- 
able for the latter purpose. 

(3) If there is a fissure or fracture, followed by no displacement, 
manipulations of the injured area must be avoided and immobilization 
m the most comfortable position applied. As a rule, plaster-of-Paris 
dressing answers the purpose best. After two or three weeks it must 
be removed and massage begun. In about two weeks a splint of 
plaster-of-Paris is applied, which the patient can take oflf and reapply. 

(4) If there is any displacement, reduction must be applied at once. 
This can be done under the control of the fluoroscope on a translucent 
table, a plaster-of-Paris dressing being applied after reposition is per- 
fect. This is a simple, short and cheap method. A more tedious, but 
a safer way is to reduce the displacement under the guidance of a 
skiagraph taken before. This will indicate in which direction the 
efforts at reduction must be made, and how far. After a plaster-01- 
Paris dressing, padded with cotton layers at its ends only, is applied, 
the skiagraph is taken through it in order to ascertain whether reposi- 
tion was complete. If it does not seem to be, the dressing must be 
removed and another attempt at reposition made. If the process of 
reduction meets with difficulties, an occurrence which can, as a rule, 
be anticipated from the nature of the skiagraph, anesthesia should be 
employed. 

(5) In those cases, in which, on account of entanglement of the 
fragments, extensive splinter formation, or similar complications, repo- 
sition 'even under anesthesia cannot be accomplished, the fragments 
must be exposed by the scalpel and brought into apposition. If there 
be no tendency to displacement, a plaster-of-Paris dressing will insure 
immobilization. But if the fragments slip out easily, it is safer to 
unite them with catgut, provided there is enough periosteum to be 
utilized for that purpose. Otherwise it is best — especially if large 
bones come into consideration — to keep them together with a bronze 
wire suture. The sooner this is done the better it will be, because the 
smaller are the changes taking place in the soft tissues. c. g. d. 



BACTERIOLOGY OF PERITONITIS. 131 



GYNECOLOGY. 



By REUBEN PETERSON, A. B., M. D., Ann Arbor, Michigan. 

ntOilllllK or GTMBCOLOGT AND OBSTBTKICS IN THE UNIYBKSITY OP MICHIGAN. 

AND 

CHRISTOPHER GREGG PARNALL, A. B.. M. D.. Ann Arbor, Michigan. 

FIKST ASSISTANT IN GTNKOLOOT AND OBBTBTRICS IN THE UNIYnSfTT OP MICIIIOAN. 



RECENT RESEARCHES INTO THE BACTERIOLOGY OF 
PERITONITIS IN RELATION TO PELVIC SURGERY. 

Sargent {Journal of Obstetrics <md Gynecology of the British 
Empire, Volume XI, Number III) devotes an extended study to the 
bacteriology of peritonitis in relation to pelvic surgery. Peritonitis is 
to be regarded as a secondary or terminal process in the course of other 
diseases, many of which may, in themselves, be without dangerously 
serious import. The avenues through which infection may enter are: 
(i) Accidental or operation wounds; (2) Rupture or perforation of 
a hollow viscus', a cyst, or an abscess; (3) Passage of germs from an 
infected, but not perforated, hollow viscus, cyst or abscess ; (4) Indirect 
infection of blood extravasated into the peritoneal cavity in such quan- 
tities as to be not readily absorbed; (5) Infection by way of the blood- 
stream. 

The writer, after many observations in cases of peritonitis in gen- 
eral, comes to the conclusion that certain types of the disease may be 
recognized and differentiated according to the kind of infecting agent. 
The organisms found were, in order of frequency, the staphylococcus 
albus, the colon bacillus, the streptococcus, bacillus pyocyaneus, pneu- 
mococcus, gonococcus, and staphylococcus aureus. Although the 
staphylococcus albus was the organism most frequently found it is 
thought to exercise a beneficial influence when associated with other 
germs as it causes a marked phagocytosis. The colon bacillus is the 
most important causative factor in peritonitis, the type of the inflamma- 
tion varying with the virulence of the infection. The streptococcus 
was rarely found, but when present gave rise to a rapidly fatal fonn of 
the disease. Of rare occurrence as causes of peritonitis are the bacillus 
pyocyaneug, the pneumococcus, and the gonococcus. 

In considering peritonitis arising from diseases of the female pelvic 
organs, the author states that the relative frequency is changed. The 
less virulent infecting agents are more common in inflammation con- 
fined to the pelvic peritoneum. Peritonitis of pelvic origin is consid- 
ered under five divisions: (i) Extrauterine gestation; (2) Salpingitis: 
(3) Inflamed ovarian cysts; (4) Infections connected with pregnancy; 
(5) Accidental infections. 

(i) Extrauterine Gestation, — In seventeen cases examined, a 
staphylococcus albus of low virulence was isolated in each case. The 



132 ORIGINAL ABSTRACTS. 

infection starts in blood clots resulting from rupture of the sac. The 
same organism was present in cases of intraabdominal hemorrhage 
following rupture of the liver and spleen. 

(2) Salpingitis, — Tubal inflammation is the most common cause of 
peritonitis met with in gynecological surgery. The process is usually 
of a comparatively mild type, occurring either by direct extension or 
through rupture. The pus sac, in case of salpingitis, generally speak- 
ing, contains the gonococcus or is sterile. Cultivation of the gonococcus 
is so difficult that this fact may account for the repeated failure of 
many observers to recognize the organism as a cause of peritonitis. 
Since the inflammatory process in cases of gonorrheal peritonitis is of 
such a mild character, it is rarely necessary to employ drainage. 

(3) Inflamed Ovarian Cysts, — Only three cases were investigated 
bacteriologically. Two of the cases showed a colon bacillus infection 
of the cyst contents, and the third a streptococcus infection of the cyst 
with staphylococcus albus present in the peritoneal exudate. 

(4) 'Infections connected ivith Pregnancy,^— No examples of these 
infections occurred. From a study of the literature, the peritonitis 
following puerperal sepsis is often of streptococcus origin and is gen- 
erally fatal. 

(5) Accidental Infections. — Any of the organisms mentioned may 
be the cause of postoperative peritonitis, the kind of infection depending 
on the location of the field of operation. One case of fatal postoperative 
peritonitis due to the bacillus pyocyaneus is mentioned. There was 
also one instance of pneumococcus peritonitis. 

From the bacteriological investigations, the author draws his con- 
clusions, regarding treatment, under the following divisions: 

( 1 ) Operative Treatment. — Since the recovery of a patient suffer- 
ing from peritonitis depends largely on the leucoc3rtes of the exudate 
acting as phagocytes, the surgeon should limit his operative inter- 
vention to thorough drainage and local cleansing. No unwarranted 
attempts should be made to remove diseased structures, and the 
leucocyte barrier must not be washed away by copious irrigation. In 
cases of intraabdominal or intrapelvic hemorrhage, the blood may be 
removed by irrigations of salt solution as the infection at first is mild, 
and there is always danger of after-infection of blood clots by virulent 
organisms. 

(2) Drug Treatment. — The writer merely considers the inadvis- 
ability of using opium. This drug masks the symptoms, may be a 
contributory agent in causing intestinal paralysis, and, according to 
Dudgeon and Ross, inhibits leucocytosis. 

(3) Specific Serum Treatment. — In all cases of peritonitis the 
writer urges an attempt to early recognize the infecting agent and 
then to employ a corresponding multivalent serum. Results, so far, 
in Sargent's experience with serum therapy, have been "sufficiently 
suggestive to w^arrant an extensive trial" of the method. c. G. p. 



EXAMINATION OF RESPIRATORY PASSAGES. 133 

PEDIATRICS. 

Bv ARTHUR DAVID HOLMES. M. D..C. M.. Detroit, Michigan. 



THE FREQUENCY, PROGNOSIS AND TREATMENT OF 
LOBAR PNEUMONIA IN INFANTS AND CHILDREN. 

KoPLiK (Boston Medical and Surgical Journal, Number I, 1905) 
says double pneumonia in children is less frequent, but involement of 
the upper lobes is more frequent as compared with adults. The prog- 
nosis depends upon the age, severity, kind of infection and complica- 
tions, but as a rule cases below the tenth year offer the best prognosis. 
The author's greatest mortality occurred below the age of two and a 
half years, and was greater in the winter months. A marked absence 
of leucocytosis foreshadows an unfavorable termination. He says a 
complicating otitis, pleurisy or empyema do not materially influence 
the prognosis, if they are recognized early, and treated properly. Hy- 
drotherapy is our sheet-anchor — sponging and cold compresses — in 
controlling the temperature if it is doing harm. If the child does not 
react well with cold, substitute tepid sponging. The author has not 
seen much benefit from the use of oxygen, but advises thorough 
ventilation, the room being kept at a temperature of 68° Fahrenheit. 
Support the heart and administer strychnin. For the cough and pain 
give codeia to the older, and paregoric to the younger children. For 
collapse, place heat to the heart and extremities and administer camphor 
and nitroglycerine. 

LARYNGOLOGY. 

By WILLIS SIDNEY ANDERSON. M. D.. Detroit, Michigan. 

ASSISTANT TO THE CHAIR OF LARYNGOLOGY IN THE DETROIT COLLEGE OP MEDICINE. 



THE CLINICAL VALUE OF THE DIRECT EXAMINATION 

OF THE RESPIRATORY AND SUPERIOR 

DIGESTIVE PASSAGES. 

Carl von Eicken (Archiv, fUr Laryngology, XV, Number III) 
gives a general resume of the value of autoscopic examinations as 
developed by Kirstein. He speaks first of its value in the examination 
of children, where it is so difficult to use a laryngoscope. It enables 
the examiner to inspect the larynx by direct vision. Foreign bodies 
in the larynx, or trachea, can be located and removed with great pre- 
cision. In stenosis and displacements of the larynx, retropharyngeal 
tumors, projections of the posterior wall of the pharynx, the direct 
method offers many advantages. The author speaks of this method 
in goitre, especially in diagnosing the endotracheal variety, or in malig- 
nant disease of the gland where the trachea is involved. Certain 
aneurysms of the ascending arch of the aorta, which are to be differ- 
entiated from intrathoracic goitre, carcinoma of the esophagus and 



134 ORIGINAL ABSTRACTS. 

Other mediastinal affections can be accurately diagnosed by direct 
tracheoscopic examinations. The bronchi and the esophagus, as well 
as the trachea, can be examined by this method, and the surgery of 
these passages can be made more exact. 



GANGRENE OF THE TONSIL. 
Charles W. Richardson {American Journal of the Medical 
Sciences, October, 1905) reports two fatal cases in his own practice 
and abstracts of three cases found reported in literature. The condition 
is rare, the laboratory findings are of little help to diagnosis, and a fatal 
termination seems to be the rule. One of the reported cases showed 
upon examination a grayish, brownish, putty-like slough on the right 
tonsil, anterior and posterior pillars and as far down the pharynx as 
one could see. The odor of the breath is always offensive, the tempera- 
ture is indicative of sepsis, and the prostration" is marked. The source 
of infection in the cases reported could not be traced. One of the 
author's cases was of the moist, the other of the dry, type of gangrene. 

PROCTOLOGY. 

Bv LOUIS JACOB HIRSCHMAN, M. D., Detroit, Michigan. 

CUmCAL PR0FBS80R OF PROCTOLOGY IN THE DBTROIT COLLBCB OF MBDICINB. 

THE TREATMENT OF HEMORRHOIDS. 

Charles B. Kelsey, in The Therapeutic Gazette, Volume XXH, 
Number HI, states that years ago he abandoned the use of the ligature 
for the clamp and cautery. The clamp and cautery in his hands has 
always been satisfactory, where the patients were willing to submit to 
operation under general anesthesia. His reasons for preferring the 
clamp to the ligature were at first that it caused less pain and gave 
quicker convalescence; now he is convinced that the pain caused by 
either operation depends far more upon the individual technique and 
skill of the operator than upon the method of closing the operation. 
He wishes to emphasize that the clamp and cautery is the last step of 
the operation for piles and not the operation itself. The operation con- 
sists of dissecting the pile from its attachments as far up toward its base 
as is consistent with safety, and the dissected mass in the grasp of the 
forceps is either cut off and tied, or clamped and cauterized. Kelsey 
usually does the latter, but on some occasions still uses the ligature as 
taught by Allingham. 

Kelsey states that either operation may be done in suitable cases 
under local anesthesia. Where the sphincters cannot be fully stretched, 
general anesthesia is demanded. He absolutely opposes the White- 
head and the "American" operation, on account of the many cases of 
stricture and ulceration following them, and states that he abandoned 
the injection treatment years ago, on account of its many septic 
sequences, and inherent dangers. After a systematic search for some 
method which would accomplish a cure without general anesthesia or 



HEREDITARY SYPHILIS. 136 

confinement to bed, Kelsey adopted the method of punctate cauteriza- 
tion by means of the galvanocautery. His technique is, briefly: Ten 
or fifteen minims of a weak eucain solution are injected into the most 
prominent part of the tumor through the Kelsey speculum until disten- 
sion is produced. After waiting for a few minutes to allow the anes- 
thetic to take eflFect, a fine platinum cautery needle, heated to redness, 
is plunged into the substance of the tumor. Not over two applications 
are made at a sitting, and these not oftener than twice a week. If 
much pain and soreness results it is well to wait a week for healing. 
This treatment takes several wrecks to effect a cure, and the patient can 
attend to his usual vocation. Kelsey reports cures of as long as ten 
years standing in prolapsing and bleeding hemorrhoids, and has never 
had an unpleasant complication or sequela. 



DERMATOLOGY. 

By WILLIAM FLEMING BREAKEY. M. D.. Ann Arbor, Michigan. 

CUNICAL PROPBSaOlt OP DSKMATOLOGT AND STFHILOLOGT IN THE UNXVKMITT OV MICHIGAN. 

AND 

JAMES FLEMING BREAKEY, M. D., Ann Arbor, Michigan. 

ASSISTANT IN DERMATOLOGY IN THE UNIVERSITY OP MICHIGAN. 



INFLUENCE OF PATERNAL INHERITANCE ON HEREDI- 
TARY SYPHILIS. 

August Ravogli (American Journal of Dermatology, October, 
1905) discusses inherent syphilis, paternal, maternal and both. 

In many cases Colles' law is but a proof of latent infection, and a 
woman married to a syphilitic man, may, during pregnancy, be infected 
by her ow^n syphilitic child. This maternal infection may be severe, 
scarcely perceptible or remain latent and after years appear as gum- 
mous or ulcerative processes. 

Syphilitic infection may be carried through the sperma as well as 
through the placenta. In spermatic infections, the fetus, saturated 
with lues, may infect the mother or the infection may remain latent in 
the fetal system. In the latter case the mother remains healthy. 

Hereditary syphilis must be divided into early hereditary and 
retarded hereditary syphilis, dependent ijpon the amount of syphilitic 
virus, the infection of both parents, the time elapsing from infection 
and the morbid intensity of the virus. 

In cases of paternal syphilis alone we more frequently find syphilis 
hereditaria tarda manifesting itself even as late as the thirtieth year. 
The symptoms are then of the tertiary type. 

Manifestations of hereditary syphilis are more frequently found at 
birth and during childhood. 

Among the various evidences of hereditary syphilis are: peculiar 
corneal inflammations often preceded by articular troubles ; Hutchinson 
teeth; retinal and choroidal troubles; modifications in* the auditory 



136 ORIGINAL ABSTRACTS. 

apparatus ; various cerebral changes, as Jacksonian epilepsy or general 
convulsions, softening from endoarteritis, infantile hemiplegia, hydro- 
cephalus and idiocy; various pathological conditions of the skin, 
mucous membranes, bones and other organs. 

The prophylactic treatment should be directed through both parents 
supplementary to treatment already taken. This consists of six months 
of mercurial and iodic treatment before procreating and the same 
treatment would better be continued to the mother through her ges- 
tation. J. F. B. 

NEUROLOGY. 

By DAVID INGLIS, M. D., Detroit, Michigan. 

PKOVBSSOR OP NBRYOUS AND MBNTAL OISBASKS IN THK DSTKOIT COLLBCB OP MBOICINB. 

AND 

IRWIN HOFFMAN NEFF, M. D.. Pontiac. Michigan. 

ASSISTANT PHYSICIAN AT THB BASTBBN MICHIGAN ASYLUM. 



THE EARLY OCULAR SIGNS OF DEMENTIA PARALYTICA. 

HoLDEN {Journal of Nervous and Mental Disease, November, 
1905, Volume XXXII, Number XI). The writer's conclusions are 
bounded on seventy cases of paretic dementia which he believed to be 
uncomplicated, that is, without cord involvement. The writer believes 
that by selecting these early cases, unattended with tabes, he has more 
nearly arrived at the condition of the pupillary reflex in paretic 
dementia. It is interesting to note that optic nerve atrophy was not 
found in one of the seventy cases reported, the author stating that he 
has found pallor of the optic disc only when symptoms of tabes or of 
nicotin poisoning complicate the cases of paretic dementia. 

The writer's recapitulation is as follows: "As this table shows, 
in true, uncomplicated paresis there is early in the disease almost 
constant absence of the sensory reflex, in half the cases irregularity 
of the pupils, in nearly half inequality of the pupils, in more than half 
abnormally small pupils, in a fifth of the cases loss of light reaction, 
in another fifth marked sluggishness of light reaction, and in a few 
of those with diminished light reaction a diminution of convergence 
reaction also." i. h. n. 



PSYCHASTHENIA: ITS CLINICAL ENTITY 
ILLUSTRATED BY A CASE. 

Schwab (Journal of Nervous and Mental Disease^ November, 
1905, Volume XXXII, Number XI). The writer quotes Janet, and 
while corroborating his views, is inclined to think that Janet's ideas of 
combining many symptoms and giving it one name is not to be at 
present commended. He, however, believes that there is a disease 
which can be distinguished from hysteria and neurasthenia, and as 
illustrative of this publishes his case, with the detailed clinical history. 

I. H. N. 



! 

i BALDNESS AND BREATHING. 137 



EDITORIAL COMMENT. 



BALDNESS ASCRIBED TO IMPROPER BREATHING. 

Doctor Delos L. Parker, of Detroit, who has been experimenting 
to determine, if possible, the factors leading to baldness, deduces some 
very interesting conclusions. To summarize, the entire theory is based 
on the contention that air, deposited in the alveoli of the lungs which 
are not utilized in the process of respiration, develops, in the presence 
of warmth and moisture, a poison which the investigator, in a series of 
preliminary studies, designated trichotoxin. The substance gaining 
entrance to the circulatory system, attacks the hair ( i ) by toxic effect, 
and (2) by depositing a crust — dandruff — upon the cranial cutis. In 
experimentation, Doctor Parker has been able to manufacture the 
poison artificially by gathering exhaled air in bottles — partially filled 
with water — and subjecting it to body temperature. By shaking the 
flasks occasionally the proper degree of moisture is maintained. In the 
course of four or five days the water is evaporated to dryness over a 
water-bath, and a residual deposit, closely resembling frost on a window 
pane, is observed. Microscopic examination discloses a crystalline 
structure closely resembling uric acid, but tests demonstrate the absence 
of this product. The deposit is composed of two substances, one of 
which is readily soluble in absolute alcohol. By allowing the alcohol, 
in which have been dissolved some of the crystals, to evaporate, the fact 
was ascertained that the insoluble crystals are larger than the soluble. 
Animal experimentation developed some interesting features. Injec- 
tions of the insoluble crystals resulted in loss of hair, while the effect 
of treatment, with the soluble crystals was merely a crust or scaly 
deposit on the skin, with no destruction of hair. Doctor Parker con- 
cludes that the insoluble product is the direct cause of baldness, while 
the soluble product is the cause of dandruff. To the insoluble substance 
the term trichotoxin — hair poison — still applies, but since the other 
substance does not affect the hair, but does affect the secretion of the 
sebaceous glands, the sebum, the term stearotoxin (meaning sebum 
poison) has been originated to represent it. 

In order to have the alveoli of all parts of the lungs utilized for 
breathing purposes, and the conditions that permit the poison of bald- 
ness to form prevented from being developed, the upper ribs must rise 
and fall with each respiratory act. In persons not bald this always 
occurs. In persons affected with baldness it does not occur. If this form 
of breathing is practiced, baldness will not develop, and if it is re-estab- 
lished and carried on continuously after being lost, baldness that may 
have resulted from its absence will be repaired. 

Doctor Parker intends to publish an extended account of his work 
in the near future. 



138 EDITORIAL COMMENT. 

MEDICINE IX POPULAR MAGAZINES. 

The importance of diffusing sound ideas of physiology and path- 
ology among thinking people is generally accepted among those who 
know. How difficult it is to secure reception for truth, and how easy 
to spread error, are both only too well known. 

A recent number of Current Literature illustrates these facts. It 
contains two medical articles. One is on the subject of "Pneumonia, 
Mice, and the Cold Cure," and will probably do no harm. The other 
is entitled "Extraction of Gastric Juice from the Live Hog." This 
opens with the somewhat illogical statement that "Natural gastric 
juice is so essential to the development of therapeutic science that the 
supply of the fluid threatens to be inadequate to meet the demand." 
Just what this means the writer may know, but how well qualified he 
is for taking up such a subject can be gathered from the next sen- 
tence, about as absurd and groundless as can be imagined : "In pul- 
monary tuberculosis the use of the natural gastric juice from an 
extraneous source has been held a condition precedent to cure." Put 
in simple language this can hardly mean anything else than that gastric 
juice must be given to patients with pulmonary tuberculosis, if they 
are to be healed. Perhaps some may have "held" this view, but how 
remote it is from modern medicine needs no remark. The article then 
quotes a newspaperese account of gastric fistula operations on pigs, 
with side-tracking of the stomach, ending: "When gastric juice is to 
be extracted, the hogs are raised into the air." If true, the animals 
would be in the same element as the abstracter's ideas. 

The question naturally arises. If the editorial omniscience is as 
faulty in matters of literature, politics, and art, what sort of an authority 
or guide is the periodical? 



A RECORD OF THE HEAT INTENSITY OF RADIUM. 

The investigations of the Swedish scientist. Angstrom, to deter- 
mine the amount of heat evoluted by the product radium, are of suffi- 
cient importance to arouse medical interest. The research of this 
worker demonstrates that the heat evolutions remain practically con- 
stant for a year, regardless of the nature of the surrounding medium, 
and accordingly the conclusion is reached that the beta and gamma 
rays form but an insignificant part of the total energy of the metal. 
The apparatus and method of determining the amount of heat evoluted 
were indeed simple. Radium bromid — 86.5 milligrams — was encased 
in a small metal cylinder, in close proximity to a second cylinder of 
similar construction, which contained a small manganine coil charged 
with an electrical current. Accurate measurement of the heat evolu- 
tions of the two cylinders was recorded by means of thermoelements. 
The cylinder containing the coil was kept at a temperature identical 
with that containing the radium, by varying the current traversing the 



LIVE BABES FROM SUBJECTS OK LUES. 139 

manganine coil, and in order to obviate error in measurement due to 
a possible metallic difference in the cylinders alternation was resorted 
to. The character of the metal employed in the cylinders apparently 
exerted little influence in the result obtained since the amount of heat 
was found to be 1.136 small calories per minute for each gram of the 
metal employed, whether lead, copper, or aluminium cylinders were 
utilized. The radium product investigated by Angstrom from Septem- 
ber, 1903, to January, 1905, evidenced no apparent alteration in the 
amount of heat evoluted. The heat effect of the metal would therefore 
seem to be due to the internal activity of the alpha particles, or to some 
agent which is decidedly different in character from the trio of rays 
mentioned. 



ANNOTATIONS, 



OCCULT THERAPY IN THE OTTOMAN EMPIRE. 

Even somnolent and superstitious Turkey is awakening to a reali- 
zation of the fraud that is perpetrated by unscrupulous medical prac- 
titioners, and a crusade against quackery of all kinds is now being 
agitated. Although the people in general are vastly too ignorant to 
appreciate skilled medical attendance, reputable practitioners are at last 
aroused to action. As elsewhere, the quacks of the Empire flourish by 
grossly deceiving the masses, most diseases being ascribed to the 
malefactions of an evil eye, while occult therapy largely constitutes the 
system of practice. 

INSECTS AS SPREADERS OF INFECTION. 

Meyer, a German physician, has conducted experiments with ants 
to determine the alacrity with which the insects carry disease germs. 
Some mice infected with typhoid were placed in a cage to which a 
colony of ants had ready access. A second cage containing uninocu- 
lated mice was placed so that the ants could gain entrance. Shortly 
the uninfected mice were perceived to develop all the symptoms of the 
disease. Plates of media over which the ants ran developed mouse 
typhoid in pure culture, and the fact that the insects can carry infec- 
tion effectively was evidenced when the investigator himself became 
ill with the disease. 



LIVE BABES FROM PREGNANT SUBJECTS OF LUES. 

Gaucher announces a treatment for syphilitic pregnant women 
which is calculated to insure a live, well-developed infant at full term. 
Essentially, an important factor is the establishment of treatment 
during the early stages of pregnancy. Mercury, the old specific sheet- 
anchor, is the remedy, but especial stress is placed on the fact that a 



140 MEDICAL NEWS. 

readily absorbable preparation must be employed. Sublimate in pill 
form for ingestion, and benzoate of mercury in alkaline solution for 
subcutaneous injection, are prescribed. Of sublimate, a centigram is 
administered, with a like amount of extract of thebane, twice daily. 
The benzoate is employed in injections of two centigrams, once daily. 
The ideal treatment contemplates alternation, giving the sublimate one 
day and the benzoate the next, permitting frequent rests from treat- 
ment during the pregnant state. In albuminuric conditions the dose by 
injection should be decreased one-half, and when elimination is faulty 
the tannate of mercury, two to ten centigrams, must succeed a period of 
milk diet. 



MEDICAL NEWS. 



AMERICAN MEDICINE BECOMES A MONTHLY. 

Doctor George M. Gould has announced the transformation of 
American Medicine from a weekly into a monthly publication. At a 
recent meeting of the stockholders there was an overwhelming senti- 
ment in favor of certain changes of policy, and the directors of the cor- 
poration were constituted a committee to inaugurate such changes as 
might seem indics^ted after due deliberation. A new series monthly is 
an innovation contemplated in the new policy. After giving assurance 
that the present "scientific, professional, and literary standards" of the 
weekly will be maintained in the monthly, the editor has this to say: 

"The cause of independent medical journalism is growing more 
important each year, and recognition of its value and necessity is becom- 
ing more general in the profession. The professionally-owned journal 
conducted in the interests of untrammeled opinion and speech, usually 
the sole medium of expression for the minorities through whom progress 
has always come, must necessarily encounter more difficulties than those 
periodicals which represent interests solely commercial, or are the 
mouthpieces of societies or other organizations, whether great or small. 
It is a matter for congratulation that there is always an emergence from 
such conditions into greater freedom and progress. Experience has 
shown, moreover, that most of what is best worth while in the profes- 
sion has been accomplished through the efforts of independent profes- 
sional journals, though too frequently the final details of the measures 
they have inspired or inaugurated must be left to the publications which, 
representing large professional bodies and hence more powerful finan- 
cially, deal naturally with measures which have become popularized and 
thus represent "majority" views. The profession is vitally concerned 
in the existence and power of its professionally-owned medical journals, 
and a large part of this interest must be directed, if it is foresighted and 
wise, to the cause of the independent medical journal. No efforts should 
be spared to make recognition of these facts more general." 



MINOR INTELLIGENCE. 141 

MINOR INTELLIGENCE. 

The Illinois Medical College is a beneficiary in the will of the late 
Doctor Addison H. Foster, a prominent Chicago physician, who 
bequeathed his valuable library to the institution. 

Doctor Leonard Lawshe Skelton, professor of neurology and 
psychiatry in the Illinois Medical College, died at his home in Chicago 
on March 14, aged forty-three years. Doctor Skelton was graduated 
from Northwestern University in 1885. 

Ballard, Washington, is to have a new hospital for the treatment 
of tuberculosis, smallpox and other contagious diseases. The projectors 
have organized a company, the capital stock of which is $100,000, and 
the plans contemplate a magnificent main building. 

The path of mystic medicine does not seem to be strewn with roses 
in any section of the country. A "mental healer" was recently con- 
victed at Sea Breeze, Florida, after a trial lasting twelve days, and 
sentenced to pay a fine of $500 and serve thirty days in jail. 

Out of five hundred volunteers, one hundred physicians have been 
chosen as subjects for experimentation by the Anti-Seasick League, 
which meets in Lisbon during April. Various remedies for the affec- 
tion will be tested, and a special steamer has been chartered that prac- 
tical demonstration may be made. 

Revocation of the charters of several of the transit companies oper- 
ating in the Borough of Manhattan is threatened. The cars, besides 
being of an antique design, are said to positively reek with filth. Since 
they have not been painted in years, and are generally in a very dilapi- 
dated condition, they are hygienically and otherwise a menace to health 
and limb. 

Carmen Sylva, in an article on "The Jews in Roumania," comes 
to the defense of her countrymen in their treatment of the Jews, by 
proclaiming that they are not inhospitable, but utterly poverty-stricken. 
She argues that the country's wealth is not sufficient for the support of 
foreigners and that her own people are barely able to obtain an 
existence. 

The suit instituted by a contagious-disease patient against the Pull- 
man Car Company, to recover damages sustained by being refused 
admittance to a passenger coach, has been won by the company, the 
Supreme Court of Alabama contending that the operators of car sys- 
tems have the right to exclude persons suffering from contagious and 
infectious diseases. 

A BILL has been introduced in the New York legislature which pro- 
vides for the creation of a state commission to regulate the practice of 
nursing. The measure provides for a commissioner and deputy, whose 
salaries shall be $7,500 and $4,500 respectively; a secretary, whose 
salary shall be $4,000 ; and a board of physicians. It is intended that 
the fees of applicants shall cover the salary expenditure. 



142 MEDICAl, NEWS. 

Professor von Behring, whose startling declaration that he had 
discovered a cure for tuberculosis was published some time ago, 
recently stated, in an address at Berlin, that the milk of immunized 
cows is a specific for the disease. Has the doctor unearthed two cures, 
or has the therapy of his first alleged remedy inadvertently leaked out? 

The Mississippi legislature recently defeated a bill to compel com- 
pounders of proprietary and patent medicines to divulge their formulae. 
Druggists of the state strongly denounced the measure as detrimental 
to their interests, inasmuch as its passage would necessitate the publi- 
cation of formulae which had taken years of experience to perfect. 

Heidelberg is to have a new Cancer Institute, and in connection 
with its opening next September, an International Congress of Cancrol- 
ogy will be held. The local authorities are pledged to furnish funds for 
the maintenance of the institution for fifty years. Nearly $200,000 has 
already been subscribed. Czerny, chief of the surgical staff at Heidel- 
berg, has resigned that post and will henceforth devote his energies to 
cancer research. 

Paul C. Freer, M. D., Pii. D., who until recently occupied the 
chair of chemistry at the University of Michigan, is now editor-in- 
chief of The Philippine Journal of Science, the first number of which 
has made its appearance. The publication is issued by the Bureau of 
Science and will chronicle the researches of the profession in the Philip- 
pines, dealing especially with problems involving bacteriology, immunity 
and tropical diseases. 

Twenty-five thousand dollars has been set aside by the trustees of 
Montefoire Hospital and Home for Chronic Invalids, in New York 
City, for the assistance of former patients of the institution who have 
either been cured or permanently relieved, the interest accruing from 
the amount being utilized for the purpose. Patients at the county 
branch of the institution — the Bedford Sanitarium for Consumptives — 
are included among the beneficiaries of the fund. 

The equipment of the Craig Colony for Epileptics is to be aug- 
mented by the construction of five additional cottages, contracts for 
which have recently been signed. When the structures are completed 
and occupied the colony will comprise about one thousand two hundred 
fifty patients. A bill is pending in the legislature for the appropriation 
of $300,000, for the construction of new buildings, and in the event of 
its passage the colony will be increased to eighteen hundred persons. 

**The name Carnrick has for nearly half a century been a sufficient 
guarantee to medical men of the ethical status of their preparations/* 
The foregoing announcement has been circulated by an Eastern con- 
cern presumably with the idea of gaining prestige, but an advertise- 
ment in the last number of this journal advises the profession that the 
instigator of the above quotation is not identified with the pioneer pharm- 
aceutic firm of Reed & Carnrick, who assume responsibility for their 
own products solely. 



ACUTE CONTAGIOUS DISKASES. 143 

RECENT LITERATURE. 



REVIEWS. 

OPERATIVE SURGERY.* 

The fourth revised edition of this valuable work is now on sale. 
Many improvements are noticeable in the illustrations. A number of 
new ones are introduced, and many of the old ones have been changed 
to conform to modern conceptions. The greatest changes are found in 
the second volume. One finds described here by text and illustration 
the latest methods of performing intestinal anastomosis, gastroenter- 
ostomy, pylorectomy, and many other new and important operations 
in the upper abdomen. One has only to read a chapter here and there 
to be convinced that the book is modernized. 

We take pleasure in introducing it to our friends who do surgery 
because they can secure accurate knowledge frorn it, and to those who 
read surgery because of its charming Myle. c. c. d. 

*By Joseph D. Bryant, M. D., Professor of the Principles and 
Practice of Surgery, Operative and Clinical Surgery, in the University 
and Bellevue Hospital Medical College; Visiting Surgeon to Bellevue 
and Saint Vincent's Hospitals ; Consulting Surgeon to the Hospital for 
Ruptured and Crippled, Woman's Hospital, and Manhattan State 
Hospital for the Insane, et cetera. 



ACUTE CONTAGIOUS DISEASES.* 

The authors have given to the profession a work that has long 
been needed. We feel that in recommending it to our readers we 
are only doing our duty. It should be in the hands of every health 
officer and of those who have much to do with the acute contagious 
disease*. Every important phase of the subject is fully considered by 
men whose years of experience with these diseases cannot help but 
enable them to speak with authority. It is a book that should be read 
and reread. The illustrations are the best that have been produced. 
Those who have had experience witjti the acute contagious diseases 
will appreciate them, and those who are doubtful of the characters of 
the closely allied eruptions will receive much help from a critical 
differential study of them. 

*A Treatise on Acute Contagious Diseases. By William M. Welch, 
M. D., Consulting Physician to the Municipal Hospital for Contagious 
and Infectious Diseases; Diagnostician to the Bureau of Health, et 
cetera, Philadelphia, and Jay F. Schamberg, A. B., M. D., Professor of 
Dermatology and of Infectious Eruptive Diseases, Philadelphia Poly- 
clinic ; Consulting Physician to the Municipal Hospital for Contagious 
and Infectious Diseases, and Assistant Diagnostician to the Philadelphia 



144 RECENT LITERATURE. 

Bureau of Health, et cetera. In one very handsome octavo volume of 
781 pages, illustrated with 109 engravings and 61 full-page plates. 
Cloth, $5.00, net; leather, $6.00, net; half morocco, $6.50, net. Lea 
Brothers & Company, Publishers, Philadelphia and New York, 1905. 



INTERNATIONAL CLINICS.* 

This volume keeps up the excellent record made by Doctor Kelly 
in the practical series it represents. Treatment, Medicine, Surgery, 
Obstetrics and Gynecology, Ophthalmology and Pathology are the 
topics for this number. It is difficult to select a few from so many 
articles — twenty-five in all — ^but among the most useful for the general 
practitioner may be named : "The Treatment of Some Common Gastric 
Disorders," by Norman B. Gwyn ; "Empyema, with a Report of Thirty 
Cases," by J. N. Hall ; "The Later Stages of Cirrhosis of the Liver," by 
Sir Dyce Dickworth; "The Thyroid Gland — Its Anomalies of Secretion 
and their Manifestations and Treatment," by Thomas R. Brown ; "The 
Results of Operations in the Treatment of Diseases of the Stomach," 
by John B. Deaver; "Phlebitis, Thrombosis and Embolism Following 
Abdominal and Pelvic Operations," by William A. Edwards; "The 
Etiology and Early Diagnosis of Acute Peritonitis," by Benjamin T. 
Tilton. Charles F. Craig has a very thorough paper on the "Symptom- 
atology and Diagnosis of Malta Fever," and Aldred S. Warthin one on 
"An Experimental Study of the Effects of Rontgen Rays upon the 
Blood-Forming Organs, with Special Reference to the Treatment of 
Leukemia." As before, the series warmly deserves the study and 
support of the profession. 

*A Quarterly of Illustrated Clinical Lectures and Especially Pre- 
pared Articles, et cetera, et cetera. Edited by A. O. J. Kelly, A. M., 
M. D. Volume IV. Fifteenth Series. 1906. Philadelphia and London : 
J. B. Lippincott Company, 1906. 



THE PRACTITIONER'S VISITING LIST.* 

This book is well adapted to make a physician's book-keeping 
reliable and accurate. It is complete in every respect. 
*Lea Brothers & Company, 1906. 



PROGRESSIVE MEDICINE.* 

Progressive Medicine for June, 1905, contains the following 
subjects: Hernia; Surgery of the Abdomen Exclusive of Hernia; 
Gynaecology ; Diseases of the Blood ; Diathetic and Metabolic Diseases ; 
EHseases of the Spleen, Thyroid Gland, and Lymphatic System; and 
Ophthalmolog}'. Each section brings into convenient form the year's 
work on the lines indicated. A comprehensive index makes the book 
valuable for rapid reference. 

*Lea Brothers & Company, Philadelphia and New York. 



% ite^ian anlr Surgeon 

A PROFESSIONAL MEDICAL JOURNAL. 



VOLUME XXVIII. APRIL, 1906. NUMBER IV. 



ORIGINAL ARTICLES- 



MEMOIRS. 



PATHOLOGIC PHYSIOLOGY OF THE TRACTUS 

GENITALIS. 

By BYRON ROBINSON, B. S., M. D., Chicago, Illinois. 

PROPBSSOR OF CYNKCOLOGV AND ABDOMINAL SURGBKY OF WOMBN IN THB ILLINOIS MEDICAL COLLBGB. 

For over a decade I have been attempting to make prominent in 
gynecologic teaching, pathologic physiology, disordered function, 
rather than pathologic anatomy, changed structure. It seems to me 
that disorder-functions or pathologic physiology of the tractus geni- 
talis impresses itself more indelibly on the student's and practitioner's 
mind than pathologic anatomy. Besides, in gynecologic practice patho- 
logic physiology occurs tenfold more frequently in the genital tract than 
pathologic anatomy. For the gynecologist pathologic physiology pre- 
sents innumerable views of practical interest. Pathologic physiology 
teaches that the circulation of an organ is a fundamental factor in com- 
prehending its disease and administering rational treatment. It takes an 
inventory of the volume of blood which streams through the organ as a 
fundamental factor in comprehending its diseases and administering 
rational treatment. It takes an inventory of the volume of the blood 
which streams through the organs at different stages and conditions. 
We wrote years ago that the arteries of different viscera were supplied 
with automatic visceral ganglia, and we christened the peculiar nerve 
nodes found in the walls and adjacent to the uterus, oviducts and 
ovaries, as "Automatic Menstrual Ganglia." The automatic menstrual 
ganglia complicates the blood supply oi the tractus genitalis by chang- 
ing its volume during the different sexual phases. In pueritas the 
blood stream of the tractus genitalis is quiescent as well as its paren- 
ch>Tnatous cells; in pubertas it is developing as well as proliferating 
parenchymatous cells. In menstruation the blood stream is active with 
active parenchymatous cells. In the puerperium there is retrogression 



146 ORIGINAL ARTICLES. 

of blood stream and an involution of parenchymatous cells. The 
climacterium is the opposite of pubertas — subsidence, the decrease 
of blood volume and parenchymatous cells. Senescence is a repetition 
of pueritas — the quiescence of the genitals, their long night of rest. 
The circulation of an organ quotes its value in the animal economy. 
It rates its function. Observe the enormous volume of blood passing 
through the kidney or pregnant uterus in a minute. 

To study pathologic physiology of any visceral tract we iViust 
possess clear views as to its physiology. The physiology of the tractus 
genitalis is: (i) Ovulation; (2) peristalsis; (3) secretion; (4) 
absorption; (5) menstruation; (6) gestation; (7) sensation. 

(i) On account of the numerous theoretic views connected with 
Ovulation and lack of space we will omit the general discussion on 
the pathologic physiology of ovulation. It is well known that ovulation 
has a wide physiologic range. We do not know the life of an ovum 
or corpus luteum. It was once supposed that a corpus luteum was a 
sign of pregnancy and the supposition gained legal or judicial position. 
We know that this is an error. I have found two corpora lutea on one 
ovary of a lamb which had not been pregnant. The internal secretion 
of the ovary is important and chiefly manifest by marked symptoms 
on removal of both ovaries — neurosis, accumulation of panniculus 
adiposus, extra growth of hair, diminished energy and ambition. These 
symptoms may occur in women possessing both ovaries, hence, we 
would conclude that pathologic physiology of ovarian secretion existed. 
The sensation of the ovary occupies a wide zone of pathologic physi- 
ology in the mental and physical being. Forty per cent of women 
visiting my office remark, "I have pain in my ovaries." On physical 
examination we find the following conditions: First and fore- 
most in the vast majority of women who complain of pain in the 
ovaries palpation of the ovaries elicits no tenderness on pressure. 
However, the pain of such women is located bilaterally in the area 
of the cutaneous distribution of the ileohypogastric and ileoin- 
guinal nerves. It is a skin hyperesthesia — a cutaneous neurosis. 
The bilateral iliac region of cutaneous hyperesthesia corresponds to the 
segmentation or somatic visceral (ovarian) area, and presents a fre- 
quent varying zone of sensory pathologic physiology. In the vast 
majority of women complaining of ovarian pain no disease of the ovary 
can be detected — it is cutaneous hyperesthesia of the ileoinguinal and 
ileohypogastric nerves. 

(2) Peristalsis (excessive, deficient, disproportionate). 

(a) Excessive peristalsis of the tractus gentalis (uterus and 
oviducts) may occur at menstruation, during gestation, parturition by 
the presence of myomata, during the expulsion of blood coagula, 
placenta during congestion. The phenomena of peristalsis in the 
uterus and oviduct differs from the form and distribution of the mus- 
cularis. The myometrium during gestation is in continual peristalsis — 
uterine unrest. By placing the hand on the abdomen of a four-month 



TRACTUS GENITALIS. 



147 




FIGURE I.— SYMPATHETIC NERVES SHOWING THE ORIGIN OF^iTHE 

GENITAL NERVES. 

S, abdominal brain : B, showing oriirin of Hpermatic (ovarian) ; F, shows origin of right genital 
nerve on the spermatic (ovarian artery) ; J, presents the plexus intenliacus which orig- 
inates in the plexus aorticus. This illustration was drawn with extreme care from a 
sperimf^n which I dissect^Mi under alcohol. It presents what I call the swan-shaped 
ureters which are diluted and prevents ureteral valves (V). IV, presents the anastomosis 
of the plexus ureteritis with the plexus spermaticus (ovaricus). 



148 ORIGINAL ARTICLES. 

gestating woman one can feel the uterine muscular waves. The ges- 
tating uterus is always prepared for an abortion but the cervix, the sen- 
tinel on guard, checks the proceeding. Fright will produce such violent, 
disordered myometrial peristalsis as to break through the guarding 
cervix. Many women during gestation experience considerable pain 
(supersensitive uterus) from excessive uterine peristalsis — it is patho- 
logic physiology. Uterine peristalsis may be sufficiently excessive to 
rupture the myometrial wall. The "after-pains," puerperal pains, is 
excessive peristalsis in an infected myometrium. Frequently the severe 
pelvic pain during menstruation is excessive uterine and oviductal peris- 
talsis due to its extramenstrual blood supply. It is chiefly the exces- 
sive peristalsis at menstruation that forces many women to assume rest 
in bed, for, with anatomic rest (maximum quietude of bones and volun- 
tary muscles) and physiologic rest (maximum quietude of visceral 
muscles) the uterine peristalsis will exist at a minimum. Excessive 
oviductal peristalsis may produce pain of varying degrees. In exces- 
sive peristalsis the automatic menstrual ganglia are stimulated by extra 
quantities of blood or by other irritation. 

(b) Deficient peristalsis of the tractus genitalis (uterus and ovi- 
ducts) is not uncommon. Uterine inertia is an example known to 
every obstetrician. Deficient uterine peristalsis allows hemorrhage in 
the fourth and fifth decades of woman's life. Deficient peristalsis 
allows extraglandular secretion (leucorrhea). 

(c) Disproportionate peristalsis is disordered, wild muscular move- 
ments in different segments of the uterus or oviduct. 

(3) Secretion (excessive, deficient, disproportionate). 

(d) Excessive secretion from the genital tract, pregnant or non- 
pregnant, has an extensive range and varying quantity. The excessive 
secretion zone in the tractus genitalis has an important bearing in prac- 
tice. Typical pathologic physiology may be observed in the pregnant 
woman from whose uterus may flow several ounces of white mucus 
daily — no pathologic anatomy is detectable. Excessive uterine secretion is 
a common gynecologic matter. The glands may not be embraced suffi- 
ciently firm by the myometrium. The automatic menstrual ganglia are 
diseased, insufficiently supplied by blood or the myometrium is degen- 
erated. Flaccid uteri secrete excessively. Excessive secretion and its 
Muid currents allows insufficient time for localization of the ovum. 
Excessive uterine secretion is, from apt bacterial media, liable to become 
infected. During excessive secretion physical examination frequently 
detects no palpable pathologic anatomy — merely physiology has 
exceeded its usual bounds. 

(e) Deficient secretion of the tractus genitalis is not so manifest as 
its opposite. The mucosa of vagina and uterus present excessive dry- 
ness, dessication, practically as visceral functions are executed by means 
of fluids, pathologic physiology is in evidence ; dryness and abrasion of 
the mucosa, local irritation, chafing, local bacterial development, dys- 
parunia, dysuria, defective import of spermatozoa and export of ova 



TRACTUS GENITALIS. 



149 




FIGURE IT.--PP:LVIC BRAIN (Adult). 



Drawn from my o-wn disnection. A, pelvic brain. In this cane it is a ganRlionat^'d plexus pos- 
sessing a wide meshwork. Also the pelvic brain is located well on the vagina, and the 
visceral sacral nerves (pelvic splanchnics) are markedly elongated; V, vagina; B, blad- 
der; O, oviduct; Ut, uterus; Ur, uret^-r ; R, rectum ; P L, plexus interiliacus (left) ; P R, 
plexu.sint«riliacus (right); N, sacral ganglia; Ur, uret^^r: 5 L, last lumbar nerve; i, ii, 
ili, iv, sacral nerves; 5, coccygeal nerve. Observe that the great vesical nerve (P) arises 
from a loop l)etween the ii and iii satjral nerves. G S, great sciatic nerve. 



150 ORIGINAL ARTICLES 

ending in sterility. Deficient secretion means that waste-laden fluids 
are bathing and irritating the thousands of lymph channels in the body. 
Deficient secretion or excessive dryness of the genital mucosa — ^patho- 
logic physiology with no perceptible pathologic anatomy — is not uncom- 
mon iq gynecologic practice. Oily applications to subjects with deficient 
genital secretion may be required for protection of exposed nerve per- 
iphery as abrasion, fissure, ulcers and also for relief. 

(f) Disproportionate secretion may occur in the different segments 
of the genital tract, unequal, excessive, deficient, irregular. 

(4) Absorption (excessive, deficient, disproportionate). 

(g) Excessive absorption presents two views, namely, a dryness of 
the genital mucosa from excessive absorption of the mucal fluids. This 
resembles the conditions arising in deficient secretion of the genital tract 
(see e). Again the mucosa of the genital tract excessively absorbs. 
Deleterious substances lying on its mucosa — septic or toxic. Excessive 
absorption in the genital tract pathologic physiology, resembles excess- 
ive absorption and conditions in other localities as the absorption of 
poison ivy, lead, arsenic among art workers. The pathologic physi- 
ology possesses a wide range for some experience no ill-effects while 
others are severely or even fatally ill from absorption of same substance 
under similar conditions. 

(h) DeHcient absorption in the tractus genitalis produces an exces- 
sive discharge, the decomposition of which lays the foundation of bac- 
terial multiplication and excoriation of mucosa and skin. 

(i) Disproportionate absorption occurs in the different segment of 
the tractus genitalis and presents pathologic physiology. However, 
lack of space makes it impractical to discuss it. 

(5) Sensation (excessive, deficient, disproportionate). 

(j) Excessive sensation in the tractus genitalis presents a wide 
zone of pathologic physiology. Vaginismus is the extreme type of 
genital hyperesthesia. The introitus vaginae of perhaps fifty per cent 
of women is supersensitive. When I was a pupil of Mr. Lawson Tait 
he had a patient, a recently married woman, from whom- the husband 
was sueing for divorce as her genital hyperesthesia was so excessive that 
coition or examination was intolerable. She had to be anesthetized to 
be examined, which was also suggested for impregnation with the hope 
that gestation would relieve the condition. Supersensitiveness of the 
pudendum is not an uncommon matter in gjnecologic practice and with- 
out demonstrative pathologic anatomy. The pathologic physiology of 
excessive sensation in the tractus genitalis has a wide range of variation 
and degree of intensity, goirie subjects may be afflicted with excessive 
sensation in the pudendum for many years. The excessive sensitive 
genitals may be manifest in the uterus or ovaries. A small number 
complain of tenderness and soreness in the internal genitals which can- 
not be detected as pathologic anatomy — simply excessive sensation. 
The gestating uterus may be so sensitive that it disorders adjacent vis- 



TRACTUS GENITALIS. 



151 



cera by reflexes. The treatment of subjects with excessive genital 
sensation requires unlimited time with continuous patience. 

(k) Deficieftt sensation of the tractus genitalis is encountered. 
With such subjects practically no orgasm occurs during coition to 
which they are indifferent. Practically little or no treatment is required. 




FIGURE III.— HISTOLOGY OF PELVIC BRAIN. 

A, drawn from the pelvic brain of a ^irl Heventeen years of age. The ganglion cells are com- 
pletely develoi>ed. B, drawn from the pelvic brtdn of a three months' normal gestation. 
The ganglion cells are complet<»ly developed. Observe the enormous mass of connective 
tissue present. C, child l}4 years old. A nerve process courses within the ganglion. 
Few and small ganglion cells incompletely developed. D, girl 1^ years old. A nerve 
process branches and reunites it«elf with the intercellular substance. B, girl years 
old. The ganglion cells are presenting development. (Redrawn after Doctor Babura 
Haahmoto). 

(1) Disproportionate sensation in the genital tract is irregular, 
indefinite, disordered, sensation arising and disappearing in its different 
segments practically without reason or rhyme. 

{6) Menstruation (excessive, deficient, disproportionate). 

I will present this subject through a clinical patient. Brief remarks 
on common examples of pathologic physiology in the tractus genitalis 



162 ORIGINAL ARTICLES. • 

will suffice to illustrate and suggest. As the most apt subject to illus- 
trate pathologic physiology in the tractus genitalis I will choose that of 
menstruation. 

To illustrate the value of pathologic physiology and the methods of 
teaching it we will place a gynecologic patient before a student to elicit 
clinical data in reference to menstruation as landmarks for diagnosis. 
A landmark is a point for consideration physiologic, anatomic, patho- 
logic. To teach gynecology- we should instruct by means of disordered 
function as a base. Menstruation is the first practical function of the 
genital tract. Hence the student asks in menstruation four questions, 
namely: (a) How old were you when the monthly flow began? The 
patient may answer: eleven (premature), fifteen (normal), or nine- 
teen (delayed) years of age. This answer presents a wide range of 
beginning of the menstrual function. Now, the girl who begins to 
menstruate at eleven generally represents pathologic physiology, but 
not pathologic anatomy. For example, the girl who begins at eleven 
(menstratio precox) will in the majority of cases menstruate profusely 
and prolonged. She will experience a late climacterium. An early 
menstruation indicates a late climacterium. Though one can palpate 
practically no pathologic anatomy, the tractus genitalis is prematurely 
developed at eleven years of age, premature in dimension (nerves, 
blood, lymph, parenchyma) and function (menstruation, gestation). 
The blood stream to the genitals is prematurely excessive, the auto- 
matic menstrual ganglia are large and prematurely active. Her men- 
strual life is accompanied by excessive blood supply and hemorrhage, 
disordered function, active parenchymatous cells, prolonged reproduc- 
tiveness. It is pathologic physiology, exaggerated function but practi- 
cally not pathologic anatomy. The girl who begins at fifteen is prac- 
tically normal during her menstrual life. No pathologic anatomy nor 
pathologic physiology is manifest. The girl who begins to menstruate 
at nineteen (menstratio retarda) is delayed with her menstrual func- 
tion ; late menstrual appearance means early climacterium ; it frequently 
indicates amenorrhea and dysmenorrhea. It generally means defect- 
ive genital blood supply and limited parenchymatous cellular activity. 
It is pathologic physiology, disordered function, limited productiveness, 
but frequently no palpable pathologic anatomy presents. .It is a fact, 
however, that in some cases atrophy or myometritis is palpable patho- 
logic anatomy and should not be confused with subjects possessing 
pathologic physiology. 

(b) The student asks the patient: Is the monthly flow regular? 
The answer may be, regular or irregular. The patient with irregular 
menstruation is afflicted with pathologic physiology but no pathologic 
anatomy may be detected. It may be stated, however, that the auto- 
matic menstrual ganglia require about eighteen months of vigorous 
blood supply to become sufiiciently strong and established to act regu- 
larly monthly. The same condition exists in the automatic vi-^ceral 



TRAC rUS GENITALIS. 



15S 



ganglia ( Auerbach's and Billroth-Meissner's) of the tractus intestinalis 
of a child. 

(c) The student, thirdly, asks the patient: Is the monthly flow 
painful? The answer may be, yes or no. A normal menstruation 
should be painless. Dysmenorrhea or painful menstruation is patho- 




KIGURE IV.— SYMPATHETIC NERVES. 

Dii«t*ctt^d with extrt^me care under al(!ohol, showinjc origin of the genital nerves flroni the 
abdominal brain, from the plexu-s ovaricus O on the right, and from the plexu.s ovaricua P 
on the left. On the right, M pre.sents the anastomosis of the plexus uret^'ris with the 
plexus ovaricus. Ph is the plexus interiliacus ari.sing proxlmally from the plexus aorti- 
eus, and ending distally in the bilateral pelvie brain. 

logic physiology, disordered function, but frequently no pathologic 
anatomy can be detected. At menstruation the blood volume in the 
tractus intestinalis rapidly increases, blood pressure is raised, compress- 
ing or traumatizing the nerves to a degree. Limited hematoma may 
occur in the endometrium, congestion is intense, inciting vigorous and 



154 ORIGINAL AKTlCLtS. 

disordered peristalisis of the uterus and oviducts. In short the trauma 
oi" shock of menstruation of the genital tract irritates it into a state of 
pain. It is a state of pathologic physiology, disordered function, but 
no pathologic anatomy may be palpable. The affliction is functional. 

(d) The student finally asks the patient: How many days does 
the monthly flow continue? The answer may be, two to eight days. 
Two days is deficient (amenorrhea or oligemia) ; four days is normal, 
eight days is excessive (menorrhagia). I have examined scores of 
gynecologic patients with over a week's flow, menorrhagia, but in many 
of them no pathologic anatomy or change of structure could be detected. 
It is typical pathologic physiology, disordered unusual function. The 
subject is like a watch with an excessively powerful mainspring. The 
watch has no detectable pathologic anatomy, no change of structure. 
The mainspring, the automatic ganglia, is excessively active. The 
organ is working excessively, the watch is gaining time. The auto- 
matic ganglia are prematurely powerful, the watch spring is too strong. 
Menorrhagia in many subjects is typical pathologicl physiology. The 
pathologic anatomy, if it exists, is too subtle for us to detect. The 
adult life of the tractus genitalis presents an excellent field for study 
and teaching in pathologic physiology. Its several periodic functions, 
its changing volume of circulation, the limited life of its parenchyma- 
tous cells and its automatic menstrual ganglia afford a useful field for 
study and development of pathologic physiology. 

(7) Gestation presents many phases of pathologic physiology. 
There is the typical pathologic physiology, namely, emesis, albuminuria, 
hypertrophy of left ventricle, pigmentation, capricious appetite, consti- 
pation, increase of panicular adiposus, the peculiar gait, venous engorge- 
ment (edema), excessive glandular secretion, osteomalacia. The vom- 
iting of pregnancy may present a vast zone from slight regurgitation 
of food to profound anemia due to limited nourishment — where path- 
ologic physiology alone tells the tale. The normal physiologic nerve 
relations between the tractus genitalis (uterus) and tractus intestinalis 
(stomach) have become disordered. No pathologic anatomy is demon- 
strable. Constipation (pathologic physiology) is liable to arise during 
gestation because the normal physiologic blood supply of the tractus 
intestinalis is robbed to supply the increasing demand of the gestating 
genital tract. The albuminuria of pregnancy is doubtless partially due 
to pressure of the expanding uterus on the ureters and veins obstruct- 
ing venous and urinal flow. The normal physiologic relations between 
the tractus urinaria and the gestating tractus genitalis has become pro- 
jected into the field of pathologic physiology. Pathologic anatomy is 
not in evidence except as ureteral dilatation — a secondary matter. A 
comprehensive view of pathologic physiology aids in diagnosis and 
treatment. It will impress the practitioners with the utility of visceral 
drainage, the administration of ample fluids at regular intervals to 
relieve the system of waste-laden blood — irritating substances. Path- 
ologic physiology teaches us to restore function and frequently patho- 
logic anatomy will take care of itself. 



TRACTUS GENITALIS. 166 

TREATMENT OF PATHOLOGIC PHYSIOLOGY OF THE TRACTUS 

GENITALIS. 

Since pathologic physiology is the zone between physiology and 
pathologic anatomy, it should be amenable to treatment. A diagnosis 
by exclusion should be made. It must be remembered that in the 
physiology the entire six abdominal visceral tracts are balanced har- 
monious, functionating without friction — no reflexes dashing hither and 
yon disturbing the exquisitively poised visceral physiology. In the 
treatment of pathologic physiology of the tractus genitalis it should be 
remembered that the genitals are not vital for life, but that the richly 
nerve-supplied genitals dominate the mental and physical existence of 
woman. In the treatment of pathologic physiology there are the sub- 
jects of periodic hyperemia, congestion, hemorrhages, excessive glan- 
dular secretions, disturbed sensation (hyperesthesia). First and fore- 
most in the treatment of pathologic physiology of the tractus genitalis, 
the adjacent visceral tracts must be regulated to normal states as to 
drainage but especially as to the physiologic condition of blood. Fre- 
quently by producing daily evacuation of the digestive tract and 
increasing the renal secretion by ample fluids the pathologic physiology 
of the genital tract improves. The genitals should be examined for 
adherent prepuce, pudendal fissure, pruritus pudendae, or other point of 
irritation. The other five abdominal visceral tracts (urinarius, intesti- 
nalis, vascularis, lymphaticus, nervosus) should be examined for 
points of visceral irritation. The frequent splanchnoptotic condition 
must be studied and remedied. 

/. VISCERAL DRAINAGE. 

For many years I have applied a treatment to such subjects which 
I term visceral drainage. Visceral drainage signifies that visceral tracts 
are placed at maximum elimination. The waste product of food and 
tissue are vigorously sewered before new ones are imposed. The most 
important principle in internal medication is ample drainage for every 
visceral tract. The residual products of food and tissue should have a 
maximum drainage in health. I suggest that ample visceral drainage 
may be executed by means of: (A) Fluids; (B) Food. 

(A) Visceral Drainage by Fluids. 

The most effective diuretic is water. One of the best laxatives is 
H2O. One of the best stimulants of renal epithelium is sodium 
chloride (one-half to one-quarter physiologic salt solution). Hence I 
administer eight ounces of half normal salt solution to a patient six times 
a day, two hours apart. (Note. — Sodium chloride is contraindicated in 
parenchymatous nephritis). Forty-eight ounces of half normal salt 
solution daily efficiently increases the drain of the kidney. It main- 
tains in mechanical suspension the insoluble uric acid; it stimulates 
other matters; it aids the sodium, potassium, or ammonium salts to 
form combination with the uric acid, producing soluble urates. The 



156 ORIGINAL ARTICLES. 

half normal salt solution effectively stimulates the peristalsis and 
epithelium of the tractus intestinalis inducing secretions which liquify 
feces, preventing constipation. 

(B) Visceral Drainage by Foods. 

The great functions of the visceral tract — peristalsis, absorption, 
secretion, sensation — are produced and maintained by fluids and foods. 
To drain the tractus genitalis and adjacent visceral tracts which should 
be excited to peristalsis, foods which leave an indigestible residue 
only are appropriate. All visceral tracts must be stimulated to maxi- 
mum peristalsis, secretion, and absorption in order to aid that of the 
tractus genitalis. Rational foods must contain appropriate salts whose 
bases may form combinations which are soluble, as sodium, potassium, 
and ammonium combined with uric acid and urates to form soluble 
urates. The proper foods are cereals, vegetables, albuminates (milk, 
eggs), mixed f(X)ds. Meats should be limited as they enhance excessive 
uric acid formation. In order to stimulate the epithelium (sensation) 
of the digestive and urinary tract with consequent increase of peris- 
talsis, absorption and secretion in both I used S part or multiple of an 
alkaline tablet of the following composition: Cascara sagrada (1-40 
grain), aloes ( 1-3 grain), sodium carbonate ( i grain), potassium car- 
bonate ( 1-3 grain), magnesium sulphate (2 grains). The tablet is used 
as follows: One-sixth to one tablet (or more as required to move the 
bowels freely, once daily) is placed on the tongue before meals and fol- 
lowed by eight ounces of water (better hot). Also 10 a. m to 3 p. m., 
and at bedtime one-sixth to one tablet is placed on the tongue and fol- 
lowed by a glassful of any fluid. In the combined treatment one-third 
of the scxlium chloride tablet (containing eleven grains) and one-sixth 
to three alkaline tablets are placed on the tongue together every two 
hours, followed by a glass of fluid. The eight ounces of fluid may be 
milk, buttermilk, eggnog — nourishing fluid. This method of treatment 
furnishes alkaline bases (sodium, potassium and ammonium) to com- 
bine with the free uric acid in the urine, producing perfectly soluble 
alkaline urates and materially diminishing the insoluble free uric acid in 
the urine. Besides the alkaline laxative tablet increases the peristalsis, 
absorption and secretion of the intestinal tract, stimulating the sensation 
of the mucosa — aiding evacuation. I have termed the sodium chloride 
and alkaline laxative method the visceral drainage treatment. The 
alkaline and sodium chloride tablets take place of the so-called mineral 
waters. I continue this dietetic treatment for weeks, months, and the 
results are remarkably successful, especially in the pathologic physi- 
ology of the visceral tracts. The urine becomes clarified like spring 
water and increases in quantity. The tractus intestinalis becomes freely 
evacuated, regularly, daily. The caliber of the tractus vascularis 
becomes a powerful fluid volume to carry oxygen and food to tissue, 
while the effete matter and waste products are rapidly swept into the 
.sewer channels. The blood is relieved of waste-laden and irritating 



TRACTUS GENITALIS. 167 

material. The tractus cutis eliminates freely and the skin becomes 
normal. The appetite increases. The sleep improves. The patient 
becomes hopeful, natural energy returns. The sewers of the body are 
drained and flushed to a maximum. 

IL— VAGINA!. DOUCHE. 

(i) The kind of instrument to employ is a fountain syringe of 
fourteen-quart capacity. The simplest and most economic vaginal 
syringe is a fourteen-quart wooden pail, the kind generally used in 
transporting candy or tobacco. 

(2) The location of the syringe should be four feet above the 
patient. 

(3) The quantity of fluid administered in the beginning should be 
two quarts for patients unaccustomed to its use and four quarts to those 
accustomed to its use. The quantity should be increased a pint at each 
administration to fourteen quarts. 

(4) The temperature of the douche should be 105° in the beginning 
and increased one degree at each administration until it is as hot as it 
can be borne (115° to 120*"). 

(5) The duration of the douche should be ten minutes for each 
gallon. 

(6) The time to administer the douche is in the evening immedi- 
ately before retiring and in the morning (after which the patient should 
lie horizontally for forty-five minutes). 

(7) The position of the patient should be lying on the back. 

(8) As to method of administering the douche the patient should lie 
on a sufiiciently inclined plane to allow the returning fluid to drain into 
a vessel (pail, pan). The ironing board, wash-tub or board resting on 
the bath-tub serves convenient purposes. The douche should not be 
administered in the bed (unless ordered), standing or sitting postures 
or on the water-closet. 

(9) As to ingredients a handful of sodium chloride and a teaspoon- 
ful of alum should be added to each gallon, the sodium chloride to 
dissolve the mucus and pus, to act as an antiseptic and to prevent 
reaction, while the alum is to astringe, check waste secretions and 
harden tissue. 

( 10) The vaginal tube employed in administering the douche should 
be sterilized, boiled, and every patient should possess her own vaginal 
tube. The most useful vaginal tube is the largest that can be con- 
veniently introduced or the one that distends the vaginal forces so that 
the hot fluids will bathe the greatest surface area of the proximal or 
upper end of the vagina. 

(11) The utility of a vaginal douche is: (a) It contracts tissue 
(muscle, elastic and connective) ; (b) it contracts vessels (lym- 
phatics, veins and arteries); (c) it absorbs exudates; (d) it checks 
secretion: (e) it stimulates; (f) it relieves pain: (g) it cleanses; (h) 



158 ORIGINAL ARTICLES. 

it checks hemorrhage; (i) it curtails inflammation; (j) it drains the 
tractus genitalis. The utility of the vaginal douche depends on the 
quantity of fluid, the degree of temperature, its composition, the 
position of the patient during administration, and on systematic methods 
of use. 

(12) Disinfectants in a vaginal douche are secondary in value to 
solvents of mucus, pus, leucocytes. 

(13) The objects to accomplish by a douche are: (a) The dissolv- 
ing of the elements in the discharge, as mucus, pus, and leucocytes ; (b) 
the mechanical removal of morbid secretions, accumulations and foreign 
bodies; (c) antisepsis; (d) diagnosis (and it includes number 11). 

( 14) The requirements of a douche ; (a) It should be nonirritating ; 
(b) it should be a clear solution; (c) it should possess solvent powers 
of pus, and especially mucus; (d) it should be continued for months; 
(e) omit the douche for four days during menstruation. 

(15) A vaginal douche, administered according to the above direc- 
tions, will prove to be of therapeutic value, in the treatment of pelvic 
disease, a prophylactic agent, and a comfort to the patient. 

( 16) The vaginal douche is contraindicated in subjects with oviduc- 
tal gestation or acute pyosalpinx as it it liable to induce rupture of the 
oviductal wall, abortion or leakage of pus through the abdominal 
oviductal sphincter. 

Ill,— VAGINAL I^AMPOiV. 

( 1 ) The composition of the vaginal tampon consists of a roll of 
medicated cotton (hen-egg size), tied to a twelve-inch string, placed 
in a solution of sixteen ounces of glycerine and two ounces of boracic 
acid. 

(2) The duration of preparation of vaginal tampon should be to lie 
in the boroglyceride solution forty-eight hours before using. 

(3) The utility of the vaginal tampon is : (a) It is hygroscopic ; (b) 
it serves as a mechanical support; (c) it contracts tissue (muscle, 
elastic, connective) ; (d) it contracts vessels (lymhatics, veins and 
arteries) ; (e) it hastens absorption of exudates; (f) it checks secre- 
tions; (g) it stimulates; (h) it curtails inflammation; (i) it drains the 
pelvic organs; (j) it cleanses; (k) it dissolves mucus, pas, and leuco- 
cytes. The utility of a vaginal tampon depends on its composition, the 
quantity employed, the duration of its application, and on systematic 
method of use. 

(5) The methods of introduction consists in placing three to five 
vaginal tampons (with, or better, without a speculum) in the vaginal 
fornices in the direction of least resistance. 

(5a) Disinfectants in a vaginal tampon is secondary to its other 
qualities, especially that of hygroscopy. 

(6) The object to accomplish by a vaginal tampon is: Maximum 
hygroscopy, dissolving the elements in the discharge, as mucus, pus. 



TRACTUS GENITALIS. 169 

leucocytes, the mechanical removal of morbid secretions, accumulation 
and foreign bodies, diagonis, and mechanical support. 

(7) The diagnosis is aided by the use of a tampon by collecting 
and preserving the uterine discharge (as pus, blood, debris). 

(8) The requirements of a vaginal tampon are: (a) It should be 
nonirritating ; (b) it should possess hygroscopic power; (c) it should 
be a solvent of discharges (mucous, pus, leucocytes, blood) ; (d) it 
should aid in the dissolving of the mechanical removal of morbid secre- 
tions, accumulations, and foreign bodies; (e) it should be aseptic (not 
necessarily antiseptic) ; (f) it should not indelibly stain the clothing 
(this is objection to its use as, for example, ichthyol) ; (g) it should 
be reasonably economic. 

(9) The frequency of application of the boroglyceride vaginal tam- 
pons should be in general, twice weekly, more frequent employment 
may cause irritation. 

(10) The time to apply the tampon is at night during maximum 
anatomic and physiologic rest. 

(11) The duration the tampon may remain usefully in position is 
ten to twenty-four hours. 

(12) There are no special contraindications to the application of the 
vaginal tampon (in pelvic disease). 

(13) The boroglyceride vaginal tampon may be beneficially applied 
in: (a) inflammatory pelvic disease (vaginitis, endometritis, myome- 
tritis, endosalpingitis, myosalpingiti3, pelvic peritonitis, proctitis, cys- 
titis) ; (b) sacropubic hernia, support for the uterus, cystocele and 
rectocele) ; (c) in genital ptosis it depletes the lymphatics and veins. 

(14) A vaginal tampon applied according to the above directions 
will prove to be of therapeutic value in the treatment of pelvic disease, 
a prophylactic agent and a comfort to the patient. 

JV,—J/AB/TAT, 

The value of fresh air was never realized so much as at present. 
Fresh cold air cures pulmonary and other tuberculosis. The success of 
the sanitarium is the continued use of fresh (cold) air. The subject 
should sleep with fresh cold air passing through an open window space 
of three by three feet. It appears to be demonstrated that cold fresh 
air is more beneficial than warm fresh air. It is common talk among 
people that one winter in the mountain is worth two summers for the 
consumptive. The curative and beneficial effect of cold fresh air con- 
tinually, day and night, for the family must be preached in season and 
out of season by physicians. The windows should be open all night. 
Fresh cold air is one of the best therapeutic agents in pathologic physi- 
ology of the tractus genitalis. 

Exercise is an essential for health. Muscles exercise a dominating 
control over circulation (blood and lymph). The abdominal muscles 
influence the caliber of the splanchnic vessels. They exercise an essen- 
tial influence over the peristalsis secretion, absorption of the tractus 



160 ORIGINAL ARTICLES. 

intestinalis, urinarius vasculoris and genitalis. The muscles massage 
the viscera, enhancing their function and the rate of circulation. In the 
uterus, the most typical example, it is prominently marked how the 
myometrium controls the blood currents like living ligatures. The 
habitat that furnishes opportunity for abundant fresh air and ample 
exercise is the one that affords the essential chances for recovery of 
pathologic physiology in the tractus genitalis. 



SOME MEDICAL MISTAKES.* 
By miles F. porter, M. D., Fort Wayne. Indiana. 

PROPRSSOR OP SURGBRY IN THB INDIANA MBOICAL COLLBGB, DBPARTMBNT OF MBDICINB OP PUKDUB 

UmVBBSITY. 

"To err is human, to forgive divine.'* To acknowledge error to 
our brothers that they may avoid erring likewise, is manly. The man 
who never makes a mistake has not yet been born. Not he who makes 
mistakes, but he who makes mistakes and fails to profit by them is a 
dangerous doctor. Experience teaches very largely through mistakes 
used as object lessons. Medical meetings might be more profitable 
were we to report more of our failures and fewer of our successes. 
There should be, in the interest of our patients, a general reciprocity in 
the profession in the matter of mistakes and failures as well as in the 
matter of successes. When such reciprocity prevails professional 
advancement will be more rapid than it is now. What appears to me 
as a mistake may appear to another more capable of judging than I, to 
be altogether good. Let us therefore talk and tell of the mistakes as 
they appear to us, frankly and fearlessly but with tolerance, having in 
mind Cromwell's admonition to the Scotch Parliament, "In the name 
of God, Gentlemen, conceive it possible that you may be mistaken." 
Nor must we forget that the methods we criticize today may be those 
we adopt tomorrow, and that the men who now seem well-nigh impos- 
sible may, as we learn to know them better, rise in our estimation until 
in the end, honesty may compel us to say of them as does Tommy 
Atkins (^f Gunga Din, 

"Though Tve belted you and flayed you 
"hy the living God that made you 
You're a better man than I am, Gunga Din." 

Let these discussions be impersonal when they may be, personal if they 
must be, always without malice, conducted with candor and always 
between ourselves. Our motto in this matter might well be, "An open 
field and a fair fight," not with a view towards determining "who is the- 
best man," but for the purpose of making us all better doctors. 

If one with so little experience as I in pedagogy might be permitted 
to speak on the subject, I would like to refer to what seems to me a 
serious error in the method of teaching, which is quite prevalent in 

♦Read at the Detroit meeting of the Northern Tri-State Medical Society. 



SOME MEDICAL MISTAKES. 161 

our medical schools. Too much effort is made to cram the student full 
of facts and too much stress is laid upon the necessity of his acquiring 
them, and too little time and energy is spent in teaching him to think, 
to reason, to see the relationship that one fact holds to another, to the 
end that if given the basic principles, he may himself deduce their 
practical application. Wisdom rather than knowledge should be the 
chief aim of both student and teacher. 

The large clinic, as a teaching medium, is very largely a farce. 
Barring the good that the student gets from the talk, and the good 
which a very few who are close to the patient get from observation, 
the large clinic serves no purpose worthy the energy and expense 
entailed. That the large clinic is still recognized as a method of teach- 
ing is due to two facts ; first, the general tendency to revere that which 
is old, and second, it is a good advertising medium for the clinician, 
and the institution under tne auspices of which it is held. We must 
increase the number of the clinics and decrease the size of the classes. 

The prevailing tendency of most students, and doctors as well, is 
toward that which is practical, hence the tendency to slight the funda- 
mental principles and take up the so-called practical branches before 
the student is prepared for this work. This tendency might be men- 
tioned as a third reason why the large clinic still flourishes. Prac- 
titioners and teachers should strive to inculcate the student's mind 
with the fact that a thorough mastery of the principles of medicme is 
necessary before one is capable of understanding the practical branches. 

The undergraduate student who pursues his studies with a view of 
l)racticing a specialty after graduation makes a grievous error and the 
schools who encourage this kind of work err likewise. To make a 
good specialist we must first have a good general practitioner. This 
entails a comprehensive study of all the branches as indicated in the 
usual four years' course supplemented by, I should say, at least five 
years of general practice. The young doctor who launches at once 
into a specialty after getting his degree, may be a very good specialist, 
comparatively, but like the man who enters upon the study of medicine 
without an adequate preliminary education, he does himself an injustice, 
because he cannot in this way do the best of which he is capable. 

We should strive also to impress prospective medical students with 
the necessity of a good education preparatory to entering upon their 
professional studies. One who takes up the study of medicine with an 
untrained mind does himself an injustice. He may succeed in making 
of himself a splendid doctor, but he cannot achieve that success which 
might have been his had he started without the handicap of an inefiicient 
preliminary education. Given a good preliminary education and a 
good medical education supplemented with a year's hospital training 
and it w-ould seem that one should be well equipped for the practice 
of his profession, but is he? Comparatively speaking, yes, but actually, 
no. He finds that hospital methods and manners are not applicable in 
private practice and the changes necessary are often not worked out 



162 ORIGINAL ARTICLES. 

under long months and sometimes years of patient and oft-times painful 
toil. Because this is true, I "am not at all sure that we gained much 
when we substituted clinical and hospital teaching for the didactic 
lecture and the apprenticeship. A year's experience w-ith a good gen- 
eral practitioner is worth more to the recent graduate in medicine than 
is a year's hospital w'ork. To have both is better, but if he can have 
but the one, then I would advise a year's practice under the direction 
of a good doctor in general practice. 

Man is a machine, and something more, he is a sentient being and 
one can gain but a very incomplete knowledge of him by studying his 
parts in a laboratory. This piecemeal study of the human body is 
valuable, it is essential in a medical education, but it is by no means 
sufficient. The doctor must study the w^hole live man, sick and sound, 
well-formed and deformed. It has seemed to me that there has lately 
been a tendency to slight the study of the patient himself for a study 
of his tissues and secretions. The value of blood analyses, urine 
analyses, cryoscopy, microscopic and bacteriologic examinations, has, 
it seems to me, been overestimated while older and more reliable 
methods of examination have been undervalued. I would not be mis- 
understood. Chemic, microscopic and bacteriologic examinations are 
valuable adjuncts in diagnosis, and we should avail ourselves of their 
help, but they are seldom as dependable as are the older methods, such 
as palpation, percussion, et cetera. 

I have known the leucocyte count to indicate pus in an appendix 
where there was no pus, and no evidences of inflammation save upon 
microscopic examination, but I have never seen rigidity and tenderness 
of the abdomen without peritonitis, nor peritonitis without tenderness 
and rigidity. I have seen a man die in uremic convulsions within 
twelve hours after a quantitative analyses of his urine showed that he 
was excreting a normal amount of urea and it was declared that he 
was in no danger from uremia. I have known a skiagraph to show 
an ugly deformity in fractures when both the functional and cosmetic 
results were perfect. On the other hand, I have seen skiagraphs that 
showed perfect results when in reality there was great deformity and 
much loss of function. 

The microscope as an aid in the diagnosis of malignant disease is 
well-nigh invaluable, but it is by no means infallible. I have known 
growths pronojLinced innocent after microscopic examination to prove 
themselves violently malignant, and I have known others to be pro- 
nounced malignant when all other evidence was to the contrary. It is 
well known that a man may be perfectly well and yet carry either 
tubercle bacilH, the Klebs-Loeffler bacillus, or the pneumococcus in the 
secretic^n of his mouth and throat. 

Have the mo<lern methods of analysis of the stomach contents 
resulted in earlier diagnosis in gastric cancer? Answering from per- 
sonal experience, I should say no, and I am not aw'are that my experi- 
ence along this line has been peculiar. » 



SOME MEDICAL MISTAKES. 163 

The natural senses unaided save by means used to make otherwise 
inaccessible parts accessible, such as anesthesia specula, et cetera, are 
the most reliable diagnostic means known, and the cultivation of these 
senses for this use remains today as the surest and best way to the 
achievement of diagnostic skill. With the creation of instruments of 
precision and the development of laboratory methods has grown up a 
tendency to neglect the study of the patient himself, a tendency to less 
careful and painstaking observation of symptoms. Just here, too, let 
me say that we are losing the art of expressing ourselves clearly and 
elegantly. Would you have proof that we are less accurate observers 
than our fathers in medicine and that we express ourselves less well, 
procure Watson's "Practice,'' Fothergill's "Handbook of Treatment," 
and compare them with like works of the present day. To be sure, we 
have gained much but we have lost also not a little. My contention 
is that we may continue to gain just as rapidly at a lesser loss than 
now obtains. 

Measured by morbidity and mortality the costliest error and the 
commonest is delay. Practically all the deaths due to appendicitis and 
strangulated hernia, and more than half of those due to tuberculosis 
and cancer might be prevented by prompt diagnosis and treatment. 
Better remove a dozen healthy appendices than to allow one to remain 
until it perforates, but there need be no necessity for doing either. 
Taxis in strangulated hernia is dangerous and should be abandoned. 
An early operation cures the hernia permanently and practically with- 
out risk. Practically all tumors should be removed as soon as their 
existence is known. This will mean the removal of many benign 
tumors to be sure, but it wall also mean the removal of malignant tumors 
in time to obtain a permanent cure. In this connection, too, it should 
be remembered that nonmalignant tumors frequently become malignant, 
so that in the end the advice to remove all tumors early will, if fol- 
lowed, result in a great decrease in the mortality and morbidity due to 
neoplasms. 

Prostatism, that bane of old men, will have largely lost its terrors 
when timely prostatectomy comes to be recognized, as it should be, as 
the only correct treatment for this condition. 

There is one more mistake quite prevalent to which I want to refer, 
namely, unnecessary dressing and meddling with wounds. I refer to 
the frequent Washings of pus cavities, the probing of sinuses, the cut- 
ting away of sloughs, the curetting of recent wounds to remove foreign 
matter, the removal of bone fragments, injured skin and muscles, and 
the frequent removal of dressings for the purpose of inspecting a 
wound. In certain cases these measures are not only permissible but 
demanded, of course, but that they are instituted all too often for the 
comfort and welfare of the patient I am convinced. To wash pus 
cavities is usually worse than useless, loose bone fragments often 
become fixed and serve a useful purpose, to cut a slough free is to 
open a new avenue for infection, skin and other tissues that seem 



164 ORIGINAL ARTICLES. 

injured beyond repair may live, curettage of recent wounds adds insult 
to injury and usually is harmful rather than beneficial, dressings prop- 
erly applied should not be changed until the wound is either healed or 
covered with granulations unless the conditions demand it. 

For all doctors to do all things necessary as soon as the necessity 
. arose, and avoid doing all things unnecessary and harmful would be 
to achieve perfection. This is impossible, hence it will ever remain 
onr blessed privilege to strive. 

207 West Wayne Street. 



TONSILLITIS AND ITS COMPLICATIONS.* 
By CHARLES F. KUHN, M. D., Detroit. Michigan. 

LBCrUKSR ON PHYSIOLOGY IN THE MICHIGAN COLLBGB OF MBDICINR AND SURGERY. 

Much has been said of late concerning the analogy between ton- 
sillitis and acute inflammatory rheumatism. It has recently fallen to 
my lot to treat a number of cases in which the sequalae have been dis- 
astrous, and I have been lead to regard tonsillitis as one' of the most 
serious diseases we have to treat, and one which, if not properly treated, 
leaves the patient in a debilitated state, susceptible to any and all 
infections. 

I believe the tonsil to be an abnormal gland or adenoid, and in exam- 
ining several hundred throats found an entire absence of the faucial 
tonsils in over half the patients, and only a rudimentary tonsil in many 
others. The existence of full-sized tonsils such as are described in 
works on anatomy is relatively rare, the largest being found in children 
and young adults. Persons with large tonsils are invariably afflicted 
with "catarrh," since being mouth-breathers in consequence of the small 
nasopharynx, various microorganisms necessarily lodge in the crypts 
of the tonsils. The tendency of the profession and laity to regard ton- 
sillitis lightly, allowing the patient to go outdoors, attend to business, 
work hard, or, if a child, to go to school, is responsible for many dam- 
aged hearts, endocarditis, hypertrophy of the heart, trachycardia, otitis 
media, deafness, pleuritis, mostoiditis, inflammatory rheumatism, 
anemia, conjunctivitis and neurosis. 

The following cases occurring in my practice, and taken from my 
clinical records, convince me of the truth of the assertions made : 

Case I. — A young man, nineteen years of age, machinist, previous 
health good, weight one hundred forty pounds, habits of life excellent, 
came to my ofiice, November 5, 1904, suffering with sore throat and 
complaining of feeling sore all over. Examination showed follicular 
tonsillitis. Temperature 101°, pulse 90; urinalysis showed specific 
gravity T020, reaction acid, and slight amount of albumin. He was 
told to return home and remain quiet until well, a diet consisting of 
milk, broths, and toast being ordered. Medicinal treatment embraced 

♦Read before the Detroit meeting of the Northern Tri- State Medical 
Association. 



TONSILLITIS AND ITS COMPLICAPIONS. 165 

fifteen grains of salicylate of soda with five minims nux vomica in elixir 
of pepsin, and a glass of water every three hours, together with a gargle 
containing twenty-five per cent of hydrogen peroxide, four times a day. 
The bowels were moved with sulphate of magnesia. On the third day 
this patient went to work feeling much better, but after laboring several 
hours became weak, and by noon had severe pains in the wrists. He 
managed to work all day, and consulted me in the evening. Examina- 
tion revealed a temperature of 102°, pulse 100, full and bounding; 
wrists swollen, red and painful to the touch. The heart and chest 
sounds were normal. Patient was advised to repair to bed and remain 
there until well. I could not keep him in bed, however, as he claimed 
he felt better when about. An erythematous eruption appeared over 
his body, and the joint symptoms followed the usual course, attacking 
nearly all the joints from time to time. Endocarditis and hypertrophy 
followed, and, despite all that was done, he died on the sixtieth day. 

Case II. — An unmarried lady, twenty years old, domestic, family 
history good, previous health and habits good, consulted me complain- 
ing of sore throat and pain in all the joints. Examination revealed 
tonsils enlarged, and covered with a follicular exudate. Temperature 
100°, pulse 90; chest and heart sounds normal. She was told to go 
home and retire to bed and not get up until well. A diet of milk and 
gruel was prescribed. Medicinal treatment contemplated salicylate of 
soda and alkalies internally, with a gargle locally. Patient continued 
her work for two days, when I called and found her in bed, suffering 
intense pain in her left knee-joint. No other joints were involved. 
She was taken to a hospital, where every attention was given her. An 
ice-bag was placed over the heart, and medication was given according 
to symptoms. Consultation was held several times, and the prognosis 
was considered favorable. The pain and swelling continued in the left 
knee-joint and endocarditis developed at the end of the first week, death 
occurring on the fourteenth day. 

Case III. — A boy, seventeen years old, laborer, appeared at my office 
with an ordinary follicular tonsillitis. He had been sick for four days. 
Temperature 101°, pulse 100; heart and chest normal; urine contained 
albumin. I saw him at his home again the next day and found him 
in great pain; temperature 104°, pulse no; dyspnea, coated tongue, 
diarrhea, and cold perspiration. Pain was referred to limbs and heart. 
An ice-bag was applied over the precordia; one-fortieth grain of sul- 
phate of strychnine was given per orem, three times a day, with infusion 
of digitalis, and twenty cubic centimeters of antistreptococcic serum 
were injected daily. I saw him again at night and found his left knee- 
joint enormously swollen and inflamed. Patient was seen in consulta- 
tion by several physicians. The endocarditis and swelling of the left 
limb continued until death, which occurred on the sixth day. 

Case IV. — A married woman, twenty-four years old, housewife. I 
was called to her home to attend her in confinement. Patient had 
always enjoyed good health. She was in labor about twenty hours, 



166 ORIGINAL ARTICLES. 

and I delivered her with instruments. The perineum was lacerated 
and I repaired this damage at .the time. The usual asepsis was observed 
preceding and during the puerperium. On the fourth day the nurse 
advised me that the patient was restless and had some fever. Exami- 
nation revealed a temperature of 102'', pulse no, respiration 24. 
Vaginal examination showed a membranous exudate on vulva and 
cervix. This was treated locally and twenty cubic centimeters of anti- 
streptococcic serum injected. Patient was examined at about 10 o'clock 
that night and local treatment applied. I washed my hands in a lysol 
solution as on other occasions and went home. About i o'clock I 
awoke with a pain in my right index finger. I could not sleep so I 
arose and found on examination a vesicle on the palmar aspect of the 
finger near the tip. I had a rigor and a very restless feeling; sore all 
over my body. By morning I had a typical tonsillitis and infected 
finger. I was quite sick for three days, two other fingers becoming 
infected, first with a vesicle, and then a pustule, which eventually 
healed. No culture was taken. I have not been able to decide whether 
I infected the patient, or whether she infected me. She recovered in 
about one week. 

Case V, — A man, twenty-two years old, bank clerk, called at my 
ofiice suffering from a slight attack of tonsillitis. The usual remedies 
were prescribed, and the patient advised to stay at home and keep 
perfectly quiet. He told me the next morning that he felt much bet- 
ter, and that as business was urgent at the bank, he thought he would 
return to work. I did not hear from him for several days, when he 
came to my office complaining of a pain in his head. Examination 
showed a normal temperature, chest and heart. I prescribed three 
grains of the sulphate of quinine and one-fourth grain of the sulphate 
of codeine, to be taken every three hours. I also admonished him to 
remain quiet. The next day he had temperature and severe pain in 
the he^d and ear. I suspected otitis media and ordered hot dry heat 
to the ear. Pain became severe and after examination I performed 
peracentesis of the drum, which afforded no relief. Pressure over the 
antrum and tip of the mastoid caused great pain, and mastoiditis was 
diagnosed, for the relief of which an operation was performed. 

Case VI. — A school girl, sixteen years old. Patient had large ser- 
rated tonsils, was anemic, and suffered with frequent headaches. I 
diagnosed neuralgia and suppurative tonsillitis. Tonsillectomy was 
performed August 7, 1904. Her general health improved gradually 
and she has been free from throat trouble, headache and neuralgia 
since. 

Case VII. — A school girl, fifteen years old. Patient had very large 
tonsils with frequent attacks of follicular tonsillitis. She always com- 
plained of severe earache during these attacks, and suffered wnth head- 
ache and shortness of breath on exertion. I advised removal of tonsils, 
but her parents objected. She is now seventeen years old and is nearly 



TONSILLITIS AND ITS COMPLICATIONS. 167 

deaf in her left ear. She also has tachycardia, the pulse rate being 140 
to 150. There is a slight hypertrophy, but no murmur or exophthalmic 
goiter. An interesting feature in this case is the family history. Her 
father and mother are healthy. The family consists of four girls and 
three boys. These children all had very large tonsils, were mouth 
breathers, had nasal catarrh and were sick a great deal. The oldest 
girl, aged nineteen, is anemic and subject to hysteroepileptic attacks. 
The younger ones had frequent attacks of sore throat and spasms. 
Four years ago I removed the tonsils of the six-year old girl and 
she has been in perfect health since. 

Case VIII. — A man, age twenty-eight, machinist. Patient has suf- 
fered with numerous attacks of follicular tonsillitis. His tonsils are 
hypertrophied and flabby. Two years ago, after an attack, he com- 
])lained of tinnitus aurium, from which he is a constant sufferer. 

From the above cases and others I am convinced that infection 
takes place through the tonsils, and that the follicles and crypts are 
the receptacles for the streptococcus, staphylococcus, Klebs-Loeffler, 
tubercle bacillus and other forms of microorganisms. Upon exami- 
nation we frequently find the tonsil diseased with sinuses leading into 
little pockets of pus. I have examined a number of patients suffering 
with endocarditis, hypertrophy of heart, pleuritis deafness and rheuma- 
tism, and giving history of perfect health before an attack of sore 
throat, for which they did nothing, or continued to work while taking 
medicine. I believe the toxins are disseminated through the lymphatics 
and blood-vessels, as the cervical and inguinal lymphatics are tender 
and enlarged, and arteritis, phlebitis, and embolism occurs in the blood- 
vessels. Patients suffering with tonsillitis should be warned of the 
danger of going out too soon. Absolute rest is most essential and the 
treatment should be thorough. The tonsils should be treated locally 
with a gargle of acetezone, normal saline solution, or one of the alkaline 
solutions on the market. Internal medication as indicated, and I have 
a preference for salicylate of soda. Existing anemia should not be 
overlooked. The tincture of chloride of iron in large doses has a good 
effect. The heart, lungs, pleura, intestinal canal and kidneys should 
be carefully watched. The diet should consist of milk, cereals and 
vegetables, meat, coffee, tea, or alcohol l)eing prohibited. Troublesome 
and enlarged tonsils should be removed, preferably with a snare, as this 
prevents hemorrhage. If only a small piece is extirpated, allowing 
drainage, good results follow in cases where the tonsils cannot be 
enucleated. Cauterization causes scar-tissue formation which is pain- 
ful and does not give satisfactory results. 

That tonsillitis is a local manifestation of a general infection, having 
a selective tendency to attack all the serous meml)ranes, lymphatics and 
blood-vessels of the body, I am certain. I have reported the al)ove 
cases rather than some terminating in uneventful recovery, with which 
we are all familiar. 



168 ORIGINAL ARTICLES. 

TRANSACTIONS. 



CLINICAL SOCIETY OF THE NEW YORK POLYCLINIC. 

STATED MEETING, MARCH 5, 1906. 

The President, JOHN J. MacPHEE, M. D., in the Chair. . 
Reported by FREDERIC^ C. KELLER, M.D., Secretary. 

READING OF PAPERS. 
RENAL COLIC. 

Doctor Edwwrd L. Keves, Jr., read a paper on this subject. He 
said, in part: Renal colic is usually considered a symptom of kidney 
stone ; but it is not absolutely pathognomic of stone nor are the position 
and character of the colic pains always an infallible index of the posi- 
tion of the stone. Indeed so misleading is renal colic in a certain few- 
cases, and yet so rarely is it a symptom of anything but stone, that 
I think it by no means waste of energy to study attentively some of the 
cases which have come under my observation and in which renal colic 
has been a misleading and often a confusing symptom. 

The late Doctor Bryson once formulated in a tentative way the 
•theory that stone in the pelvis of the kidney causes pain in the loin 
radiating down the ureter, while stone at the lower end of the ureter 
causes frequent and painful urination and pain in the pelvis. This 
distinction holds true in the great majority of cases; yet I have seen 
one case that was a striking exception to this rule, in that the only pain 
suffered was from frequent and painful urination, although the patient 
had but one stone, and that lay in the pelvis of his kidney. 

The first patient, a lean asthmatic man, sixty-three years old, com- 
l)lained of frequent urination. Sixteen years ago he applied for 
insurance and was refused on account of albuminuria. He consulted 
a surgeon, who stated that he had a surgical inflammation of the 
kidney. Except for the passage of two calculi from thd' right kidney, 
eight and five years ago respectively, and except that he had to rise 
once or twice at night to empty his bladder, there were no symptoms 
until aboni a year a^^o, when his urination became more frequent and 
he consulted an eminent urologist who began and has since continued 
treating him for chronic cystitis attributed to prostatic hypertrophy. 
His symptoms have grown gradually worse. 

Examination showed the right kidney to be readily palpable, some- 
what large and tender ; the left kidney could just be felt, but was not 
tender. The urine was hazy with pus; specific gravity 1016; albumin 
one per cent by weight ; various casts of many kinds ; many red blood 
cells ; a total excretion of from twenty-five to thirty ounces ; the bladder 
capacity was eight and one-half ounces. The prostate was not enlarged ; 
there was no residual urine. A'-ray examination revealed a shad<.Av in 



CLINICAL SOCIETY. 169 

the region of the right'kidney pelvis, but for various reasons the opera- 
tion was postponed for eighteen months, when the patient's condition 
was so unsatisfactory that it became inperative. 

Upon opening the right kidney, an oxalate stone was found fitting 
in the upper end of the ureter and was removed through an incision 
in the kidney pelvis. The kidney itself was considerably dilated and 
covered with small cysts which contained serous, bloody and sero- 
purulent fluid. It was suspected, because of the nature of the symp- 
toms, that there was a stone in the ureter, but careful search failed to 
reveal one. 

After operation, instead of passing urine constantly, as he had done 
heretofore, he had to be catherized until the second day, when he began 
to urinate at intervals of from two to four hours. The secretion of 
urine remained low, and, finally, at the end of three and a half weeks, 
the patient died from asthenia and failure of kidney function. 

It is noteworthy that in this case we were able to arrive at a diag- 
nosis with the aid of an A'-ray photograph, while the practitioner who 
had previously treated it had failed to make the diagnosis because he 
had not employed this expedient. 

In contrast to the above case, in which a patient with stone suffered 
from a pain that did not resemble renal colic, the second case shows 
the brilliant contrast of a patient with renal colic, but without stone. 

The patient, fifty-eight years of age, complained of repeated attacks 
of renal colic. He never passed blood, never had any anuria or bladder 
symptoms, although since the first attack he had urinated twice at night 
and every three hours by day. No lumbar tenderness could be evoked 
by palpation, nor was it possible to feel either kidney. X-ray photo- 
graphs showed small sclerotic kidneys, but no shadow suggestive of 
stone. Examination of urine showed many pus cells, no bacteria, 
and but very few blood cells. Macro*scopically there was no pus. He 
was given an alkaline mixture, advised to drink very freely of water 
and to exercise to the limit of toleration ; and I believe that in January, 
1906, he had no further renal colic. 

A detailed history is omitted of a patient who suflFered from most 
violent attacks of renal colic brought on by digestive causes. A 
carefully restricted diet, much exercise and water, and the administra- 
tion of beta-naphthol, bismuth and salol caused a cessation of these 
attacks. 

In further contrast to this case was one, in which the colic caused 
by digestive disturbance was intestinal and not renal, although the pain 
was precisely that of renal colic. 

The last history of which I have record is an example of a class 
of cases which I consider very important. They are relatively infre- 
quent and cause objective symptoms absolutely characteristic of renal 
stone; yet a careful examination will reveal the fact that they suffer 
from nothing more than seminal vesiculitis. 



170 ORIGINAL ARTICLES. 

RKPORTS OF CASES. 
PARTIAL GASTRECTOMY FOR CARCINOMA, 

Doctor Joseph I. Edgerton : I wish to present this patient, a male, 
forty-one years of age. His father is living and in good health at 
seventy-eight; mother died of stomach trouble, probably cancer, at 
fifty-eight years of age. Patient had malaria severely twenty-five years 
ago, but has had no recurrences. He indulges moderately in tea, coffee, 
and alcohol, and smokes regularly from fifteen to twenty cigarettes 
daily. For the past thirteen years he suffered with heartburn, which 
has been more constant during the past two years, during which time 
he also suffered from nausea and pain in the epigastrium after eating. 
During the last few months he had burning pains after eating; was 
hungry all the time, but afraid to satisfy his hunger, for when he took 
solid food it remained in the stomach for an hour or so, and then 
was vomited. On one occasion last winter he vomited some mucus 
streaked with blood. He began washing out the stomach twice a day 
on October 4, and brought up greenish clumps of mucus resembling 
moss. There w^as no vertigo. His bowels were constipated, and he 
lost about twenty-five pounds in weight during the last few months. 

On November 27, 1905, the stomach contents contained free hydro- 
chloric acid ; moderate reaction ; odor butyric. A mass could be felt 
over the region of the pylorus, and operation was advised and accepted 
by the patient. The usual preparation of cleansing the stomach by 
lavage was performed, and in the operation Mayo's technic was fol- 
lowed. The abdomen was opened near the median line and the gastric 
artery was doubled, ligated and divided near the cardia. The gastro- 
hepatic omentum was also doubled and ligated close to the liver, leaving 
most of its structure attached to the stomach. The superior pyloric 
artery was treated in the same manner, and the upper inch or more 
of the duodenum was freed. With the fingers as a guide beneath the 
pylorus in the lesser cavity of the peritoneum, the right gastroduodenal 
artery was ligated. The gastrocolic omentum was cut distal to the 
glands and vessels up, to an appropriate point on the greater curvature 
and the left gastroepiploic vessels were ligated. With a running suture 
of catgut through the seared stump the end of the duodenum was 
closed. The proximal end of the stomach was double-clamped along 
the Miculicz-Hartman line, and divided with a cautery, leaving one- 
(juarter inch projection. Then gastrojejunostomy was done. The 
tumor was found to occupy the pyloric end of the stomach, extending 
around the whole circumference. No adhesions were present. There 
was a delay in finding tftle nearest point of the jejunum that could be 
brought to the stomach wall and in taking great pains to suture the 
opening in the mesocolon so as to prevent hernia into the lesser cavity 
of the peritoneum. 

His temperature at no time following the operation was above 99.6° 
Fahrenheit, and there has been no vomiting since operation. He took 
water in eight hours and liquid nourishment in twenty-four. His 



CLINICAI- SOCIETY. 171 

bowels were moved by enemas during the first week, but there was no 
distention ; in fact, no more discomfort than from an ordinary explora- 
tory laparotomy alone. The man has gained about twenty-five pounds 
in weight and is at his regular employment again with no discomfort 
whatever referred to his stomach. 

CASE OF MORPHINE POISONING, 

Doctor Daniel A, Sinclair : I wish to report the case of a patient 
who is sixty-three years of age, weighs one hundred eighty pounds, is 
five feet six inches in height, full blooded, with marked organic heart 
disease. He has been coming to my office for the past two or three 
years suffering from alcoholism. He is a periodic drinker, and when 
first seen, two or three years ago, had been treated along the regular 
lines for such a condition. He freely informed me that he had been 
in the habit of receiving injections of morphine from previous doctors 
and that was the only treatment that did him any good. Accordingly 
one-quarter of a grain of morphine was injected, which the patient 
reported at the next visit was of no benefit whatever, stating that it 
was, he knew% a very small amount — nothing like what he had been 
used to getting. The dose of morphine was very carefully increased 
to one-half grain without any effect, and finally, at the earnest solicita- 
tion of the patient and his assurances that he could stand the morphine, 
the dose was increased to one grain. This injection bore out his state- 
ments as to his previous experiences and "just about steadied him," 
without producing anything but a very short sleep. His subsequent 
periodic sprees were treated along the same lines, from three-quarters 
to one grain being used at an injection. It became so much a 
matter of course to. inject this patient and see no untoward effects 
whatsoever that there was no hesitation about giving him a grain of 
morphine two or three times a day, according to the exigencies of the 
occasion. Between the sprees the man, who was of more than average 
intelligence, not only abstained from alcohol, but did not have the 
slightest desire for morphine or any other drug. 

The treatment detailed above was carried out until the last spree, 
about a month ago. On this occasion he presented himself, intoxicated, 
but retaining all his faculties, and begged for an injection of morphine, 
saying that he would only be put "on the ragged edge," as he expressed 
it, if he received the usual dose. He stated that he had taken as many 
as three grains of morphine without any bad effects, but this statement 
he afterward denied. He had a very important meeting for the next 
day, and therefore was desirous of securing a good night's rest. One 
and one-half grains of morphine sulphate were injected into his left 
arm. In about half an hour I was called to him hurriedly, and found 
him in a much stupified condition. This was about 8 p. m. ; a small 
dose of cocain was injected and I left, returning about 9 o'clock, when 
the patient was breathing slowly, about five or six a minute. He was 
walked up and down until about 1 1 o'clock, at w^hich time his respira- 
tions had diminished to one in two minutes. Up to this time there had 



172 ORIGINAL ARTICLES. 

been injected hypodermatically 3/5 of a grain of cocain, 4/150 of 
atropine sulphate, 4/30 of strychnine and 4/100 of nitroglycerine. 
He had also been given about a quart of strong, black coffee. The 
situation being desperate, at the request of the man's family 1/12 of 
apomorphine sulphate was injected as an emetic and was effectual in 
about one-half minute. The patient went steadily into a deep coma, 
became very blue and was apparently dying. Artificial respiration 
and the administration of oxygen were then resorted to and the tongue 
pulled forward with artery forceps. At 1 130 p. m. he began breathing 
at the rate of about four a minute. About a quart of black coffee was 
given as an enema and about 3 a. m. he was breathing about ten times 
a minute and was conscious. 

The oxygen and artificial respiration, together with the cocain, 
probably saved the man's life. Two lessons should be learned from 
this case : ( i ) Not to be importuned into giving any patient a large 
dose of morphine, even though he is used to it ; and, (2) not to abandon 
hope or relax one's efforts, even when the patient is apparently beyond 
hope, as this case show^s that even in apparently fatal cases life may 
be saved. 

DISCUSSION. 

Doctor Robert IT. M. Dawbarn : This case recalls to my mind a 
case of morphine poisoning which occurred when I was interne at the 
Nursery and Child's Hospital. I placed the patient on his back and 
administered atropine (the first dose of which dilated the tubes) until, 
from morphine poisoning, the patient developed a case of atropine 
poisoning. Life was saved by artificial respiration, which was kept 
up for eight hours by myself and assistant, each taking two-minute 
turns. Walking the patient up and down was tried, but the exertion 
seemed only to make the heart w^eaker. If I were to criticise the treat- 
ment of the case under discussion, it would be the giving of depressing 
narcotics, as after vomiting from an overdose of morphine the patient 
usually collapses. 

Doctor Maurice Packard : In a series of experiments, in which I 
have been interested, which were being conducted by Doctors Bodine 
and Jeffries, they were trying to find out from guinea pigs how much 
morphine w^ould act as an antidote for a given injection of cocain, 
acting upon the principle that cocain is a physiological antidote for 
morphine. Previously atropine had been used for this purpose, but 
atropine and morphine acted similarly, in that both have a tendency 
to depress the smooth muscle fibres as well as secretion, while, on the 
other hand, cocain stimulates the smooth muscle fibres and increases 
secretion, as is shown by the druling at the mouth and the frequency 
of urination. The best possible treatment, I think, is the stomach 
tube. After using it once, however, it must be used every half hour, 
for the mucous membrane of the stomach repeatedly secretes morphine. 
With the stomach tube and the proper use of cocain, most of these 
cases will end in recovery. 



DIAGNOSTIC SIGNIFICANCE OF COLIC. 173 

ORIGINAL ABSTRACTS. 



MEDICINE. 

By GEORGE DOCK, A.M., M. D., D. Sc. Ann Arbor. Michigan. 

PKOPBSSOR or MBDICINB IN THB UNIVBRSITY 09 MICHIGAN. 

AND 

DAVID MURRAY COWIE, M. D., Ann Arbor. Michigan. 

FIRST ASSISTANT IN MBDICINB IN THB UNIVBRSITY OV MICHIGAN. 



HYPERTROPHIC STENOSIS OF THE PYLORUS. 

Rogers (Archives of Pediatrics, March, 1906) reports a case of 
hypertrophic stenosis of the pylorus in an infant of three weeks. Med- 
ical treatment was persisted in until the third month, when operation 
by posterior gastro-jejunostomy was performed. Patient recovered. 
The symptoms of nearly complete stenosis of the pylorus in children 
are very stereotyped, and in the beginning of the gastric disturbance 
they are always suggestive. Any considerable amount of food in the 
stomach nine hours after the last meal, as was observed in the author*s 
case, especially if present on more than one occasion and accompanied 
by other symptoms of obstruction, should always determine the advisa- 
bility of immediate surgical interference. This case well illustrates the 
hopelessness of medical treatment. Improvement from time to time 
will raise the hope that operative measures may not be necessary. Such 
improvement is usually deceptive. Rogers' case is the third successful 
operative case reported from this country. The operation was per- 
formed under ether and occupied twenty-five minutes. d. ^r. c. 



SURGERY. 

By frank BANGHART WaLKER, Ph. B., M. D., Detroit, Michigan. 

rROVBSSOR OV SURGBRT AND OPBKATIVR SURGRRY IN THB DETROIT POSTGRADUATB SCHOOL OP MBDICINB; 
ADJUNCT PROPRSSOR OP OPBl(ATIV8 SURGBRY IN THB DBTROIT COLLBG8 OP MBDICINB. 

AND 

CYRENUS GARRITT DARLING. M. D., Ann Arbor. Michigan. 

CLINICAL PROPBSSOR OP SURGBRT IN THB UNIVBRSITY OP MICHIGAN. 



THE DIACiXOSTIC SIGNIFICAX'CE OF COLIC. 

In the Nezv York Medical Journal, Volume LXXXIII, Number 
XII, La Roque brings out the characteristic features of colic from dif- 
ferent sources and contrasts it with peritonitis. 

He refers to the common inclusion of most manifestations of 
abdominal pain under the term colic but thinks it should be limited to 
designate spasmodic involuntary muscular contraction of the walls of 
an intraabdominal viscus or canal. The commonest causes he states 
are found in the gastrointestinal tract, biliary and pancreatig passages. 



174 ORIGINAL ABSTRACTS. 

urinary apparatus and female generative organs. They may be inci- 
dent to irritative lesions as inflammation or fermentation and their 
products, including gaseous distention, to obstructive lesions as foreign 
bodies, invagination, torsion and constriction from without, and to 
nervomuscular incoordination as in lead poisoning and certain other 
intoxications. 

Certain symptoms are common to all varieties of colic, as the 
paroxysmal pain, its sudden onset and griping character, restlessness, 
et cetera. Certain other symptoms are referable to functional or 
anatomic alterations in the structure involved. In affections involving 
principally the stomach the pain is referred chiefly to the epigastrium. 
Colicky pain of the intestine is often most severe in the region about 
the umbilicus. Diarrhea generally indicates intestinal disease, and the 
intensity of it is greatest in diffuse colonic disease. In general the 
darker and more intimately mixed is the blood in the feces, the 
higher is its origin. The false diarrhea incident to mechanical obstruc- 
tion about the ileocecal junction is scanty, mucoid, often bloody in 
character, with little fecal matter and often associated with tenesmus. 
Ihe spasmodic vomiting of colic is expulsive, often violent, and in 
general it may be said that the intensity of vomiting varies directly 
with the height of the lesion and inversely with the severity of the 
diarrhea. Except in intestinal obstruction, however, vomiting is never 
stercoraceous. Colic is usually the first symptom of plumbism. The 
chief diagnostic features are : Constipation, flat or retracted rigid belly, 
associated cramps in other muscles, slow, wiry pulse and the absence 
of all signs of intraabdominal inflammation. In connection with tabes 
colic may be gastrointestinal, renal, ureteral, vesical, and even rectal, 
bronchial, laryngeal and other affections are not unheard of. Biliary 
colic begins and is most severe in the region of the gall-bladder, from 
which it radiates along the course of the intercostal nerves to the right 
scapula. Pancreatic colic is not frequent. Renal or ureteral colic 
begins over the region of the kidney and radiates downward and ante- 
riorly. Uterine, tubal and ovarian colic are commonly combined and 
often indistinguishable. Pelvic examination generally detects the 
cause. 

In every case of abdominal pain the phenomena of colic must be 
immediately differentiated from those of peritonitis. The author has 
presented the following table: 

PAIN. 

Colic. Peritonitis. 

Less sudden onset. * !More sudden onset. 

Gradually rising to maximum. May be preceded by the pain of the 

Waxing and waning in intensity. primary lesion. 

Paroxysmal. No spontaneous waning in intensity, 

Less positively localized to a point of persistently severe, often positively 

greatest intensity. localized, and unless diffuse, there 

is always a point of greatest inten- 
siiv. 



DIAGNOSTIC SIGNIFICANCE OF COLIC. 175 

DECUBITUS. 

Generally doubled up, patient may lie Thighs may be flexed, but no positive 

in any position. Restlessness is doubling up. Dorsal decubitus is 

marked by frequent changes in po- generally assumed, and instinctive- 

sition. ly maintained. 

VOMITING. 

May or may not occur, when present Practically always occurs, and is of 

is expulsive in type. the easy type. 

BOWELS. 

Constipation only accidental except Constipation marked though purg^- 

in intestinal obstruction and in tives in large doses may be effect- 

plumbism. ive. 

Purgatives are effective except in ob- Diarrhea never present except in per- 

struction. itonitis arising from pelvic organs. 
Diarrhea may be a part of symptom 

complex. 

PERISTALSIS. 

Normal or exaggerated. Never exaggerated. 

Absent in the segment of gut in- 
volved, but in local peritonitis this 
is difficult to determine. 

TENDERNESS. 

Cutaneous sensibility greatly cxag- Skin tenderness insignificant as com- 

gerated, broad, steady, deep pres- pared with the fixed deep-seated 

sure is grateful, though a vague excruciating tenderness, 

deep seated tenderness of the caus- 
ative lesion may be elicited. 

MUSCULAR RIGIDITY. 

Never positive nor continuous except Always reflex and continuous. Not 

in plumbism or great distention. easily overcome by pressure. In 

May be overcome by gentle, steady localized disease may be circum- 

pressure, and is not confined to a scribed, 
small circumscribed area. 

DLM'HRAGMATIC MOBILITY. 

Never impaired except by great dis- Generally reflexly diminished, espe- 

tention. cially when the upper abdomen is 

Movements are not generally causa- involved. Sudden eflforts, such as 

tive of pain. coughing and deep breathing, are 

painful. 

METEORISM. 

May or may not occur, not charac- Generally noted early, though in 

teristic except in obstruction. many cases slight, till disease be- 

comes well marked. 

LEUC OCYTOSIS. 

Rarely present, and never progres- May not be present, but generally ex- 

sive. ists, and if nrogressive. is of diag- 

nostic value. 

FEVER. 

May or may not exist. A sudden fever, especially if preceded by rigor, points 
to peritonitis, though its absence is perfectly compatible with this disease. 



176 ORIGINAL ABSTRACTS. 

GYNECOLOGY, 



By REUBEN PETERSON, A. B.. M. D., Ann Arbor, Michigan. 

PROPBSSOR OP GTNSCOLOGT AND OBSTBTKICS IN TKB UNIVBKSITY OF MICHIGAN. 

AND 

CHRISTOPHER GREGG PARNALL, A. B., M. D.. Ann Arbor, Michigan. 

PIRST ASSISTANT IN GTNBCOLOGT AND OBSTETRICS IN THB UNIVBRSITY OP MICHIGAN. 



DU M£AT HYPOGASTRIQUE ET DE UEPISIORRAPHIE 

APPLIQUfiE AU TRAITMENT DE CERTAINES FIS- 

TULES UR£THRO-V6SICO-VALGINALES. 

CiiENiEUX {Reviie de gynecologic et de chirurgie abdominale, Vol- 
ume X, Number I) describes an operation for certain cases of urethro- 
vesico-vaginal fistulae. This operation is to be used only in rare cases., 
for exceptional indications, when other procedures have failed, or 
would fail if employed. In the repair of urinary fistulae the object is 
to restore control. Under various circumstances this cannot be done, 
for instance, in cases where the adhesions, the extent, or the location 
of the fistulous opening are such that complete closure is impos- 
sible, or when the sphincter of the bladder is involved so that repair of 
the fistula will not cure the incontinence. 

The writer reports a case in which he employed his operation. A 
woman, aged twenty-six, after a difficult labor, suffered from inconti- 
nence of urine. Marked leakage took place without regard to the 
position assumed. ILxamination showed practically a destruction of 
the cervix and the anterior vaginal wall. The borders of the extensive 
fistula were indurated and adherent at the sides to the pelvic bones, 
posteriorly to the remains of the uterus. The fistula was classified as 
urethro-vesico-vaginal, for the whole urethra as well as the floor of 
the bladder had disappeared. Such cases are extremely rare and can- 
not be treated by any of the more common operative procedures. 

The method used in this case was a modification of that practiced 
by Maisonneuve, Baker-Brown, and Rose, and consisted in the estab- 
lishment of a communication between the bladder and the rectum with 
closure of the vaginal and urethral openings. The operation is done 
by making two large lateral flaps consisting each of one labium majus 
with the surrounding tissue. The base or pedicle of one flap lies in a 
line from the anterior commissure, along the edge of the introitus, to 
the center of the perineum. The base of the second flap lies well out 
at the fold forming the junction of the skin of the thigh and vulva. 
The first flap is now turned, raw surface outward, into the bed formed 
by dissecting loose the other flap, and sutured in place. The second 
flap is now shifted over the raw surface to cover it with skin. This 
fla]) is now sutured to the margin of the incision which outlined the 
first flap. In- this way the meatus and the vaginal orifice are securely 
closed. The opening between the vagina and the rectum, which is 
made before the vulvar introitus is occluded, is utilized, subsequently. 



SUBSTITUTE FEEDING IN INFANTS. 177 

as an avenue through which a canula with an obturator is passed to 
irrigate the vesical portion of the artificial cloaca, in order to prevent 
the formation of calculi. With 'proper instruction, the patient herself 
will be able to carry out this procedure. 

The results of the operation are not fully stated. The writer does 
not discuss the possibility of ascending infection of the urinary tract 
and no idea is given as to how long the patient could retain urine. A 
difficulty experienced by some surgeons after similar operations is con- 
traction of the edges of the artificial fistula between the vagina and the 
rectum, necessitating a more extensive opening by a subsequent oper- 
ation, c. G. p. 



PEDIATRICS. 

By ARTHUR DAVID HOLMES, M. D.,C. M., Detroit, Michigan* 



SUBSTITUTE FEEDING IN INFANTS. 

Sanderson Wells (Sritish Medical Journal, July 8, 1905) says 
any food not conforming with the standard composition and properties 
of mother's milk must be rejected. He says artificial foods as a class 
are bad, and believes wet-nursing inadvisable as it is inaccurate, incon- 
venient and dangerous, because we cannot exclude syphilis. The author 
relies on the modification of cow*s milk and draws the following 
conclusions : 

(i) That mother's milk is the only proper food for infants and 
should be used whenever available. 

(2) That all forms of proprietary foods are bad and to be avoided. 

(3) That wet-nursing is rarely permissible. 

(4) That the proper substitute food for infants is some form of 
modified cow's milk. 

Also the following special conclusions: 

(i) That the standard at which we aim in modifying cow's milk 
is the child's natural food — mother's milk. 

(2) That careful attention must be paid to each of the constituents — . 
proteid, fat, sugar and salts. 

(3) That the proteid of cow's milk is less digestible than that of 
human milk and requires overdilution compared with that of the 
standard. 

(4) That the whole of this indigestible proteid (caseinogen) may 
be removed, leaving the more easily digestible proteid (lactalbumen) 
as in whey mixtures, or that the proteid content may be completely or 
partially peptonized. 

(5) That cow's milk diluted sufficiently to bring the proteid into 
line with the standard (that is, from four per cent to 1.5 per cent) is 
deficient in fat and sugar, and that these must be subsequently added. 

(6) That fat may be added in the form of cream, either separated 
and of standard strength, or by using gravity creams. 

(7) That lactose is the proper sugar to add. 



178 ORIGINAL ABSTRACTS. 

(8) That cow's milk, although neutral or alkaline when drawn, 
owing to its certain infection as at present obtained and to the rapid 
growth of germs it allows, beccMnes acid, and that this acidity must be 
neutralized by bircarbonate of soda or limewater. 

(9) That human milk is sterile. From this it follows that we should 
endeavor by all the means in our power to obtain a supply of sterile 
cow's milk. 

(10) Germs must be killed by some method. The handiest and 
most generally used being heat. 

To his previous conclusions he adds the following : 

( 1 ) That some attempt must be made to kill germs always present 
in large quantities in milk. 

(2) That boiling does this most effectually and rapidly, is much 
the easier method, and, in the hands of the poor, often the only method 
available, but that certain injurious changes result, to be avoided if 
possible. 

(3) That these changes can best be avoided at 70° centigrade 
(158° Fahrenheit) for half an hour (Pasteurization). 

(4) That all infant's food should therefore undergo this process 
when possible. 

ORTHOPEDICS. 

By IRA DEAN LOREE, M.D., Ann Arbor, Michigan. 

FIRST ASSISTANT IN SUKGBRY IN THE UNIVBKSITY OF MICHIGAN. 



CONGENITAL COXA VARA. 

Henry O. Feiss, M. D., of Cleveland, in Jamaj February 24, 1906. 

He gives the history of one case with arguments favoring its origin 
as intrauterine. The article contains a summary of certain experiments 
performed upon the dead fetus. These consisted in fixing the limbs 
in certain positions that might be assumed before birth and then noting 
the relations of the parts by means of the radiograph. 

He concludes that the deformity comes most commonly with defects 
of the femur of the lower limbs. That it may be intrauterine in its 
strictest sense, from intrauterine infection or combined with congenital 
rachitic deformities. 



LARYNGOLOGY. 

By WILLIS SIDNEY ANDERSON, M. D., Detroit, Michigan. 

ASSISTANT TO THB CHAIR OF LARYNGOLOGY IN THB DETROIT COLLEGE OF MEDICINE. 



A CONTRIBUTION TO THE STUDY OF THE ETIOLOGY 
OF NASAL OBSTRUCTION. 
WiLHELM RoTH (Rcvue Hebdomodoire de Laryngologie, d'Otolo- 
gie et de Rhinologie, January 20, 1906) calls attention to those cases 
where the antrum of Highmore is involved, and where the secretion 
is of such consistence that none of it flows out into the nasal fossa. 



r 



SPHINCTER AND FISSURE. 179 

Examination of the nose shows no secretion, nor the usual evidence 
of sinus involvement. These cases are accompanied by nasal obstruc- 
tion of the side corresponding to the sinus involved. The swelling in 
the nose involves the cavernous tissue, and it promptly shrinks after 
the application of cocain. No anatomical reason can be found to 
account for the nasal obstruction. If the antrum be thoroughly 
washed out, the nasal obstruction will promptly disappear. If the 
secretions are again allowed to accumulate in the sinus, the nasal 
obstruction will recur. The author believes that the cause of the 
swelling of the cavernous tissue is the reflex vasomotor irritation due 
to the accumulation of the secretion in the sinus. Roth holds that this 
type of sinus disease is an important factor in the etiology of unilateral 
nasal obstruction, where no anatomical cause can be found to account 
for the nasal condition. 



PROCTOLOGY. 

By LOUIS JACOB HIRSCHMAN, M. D., Detroit, Michigan. 

CLINICAL PROVKSSOR OV PROCTOLOGY IN THB DBTROIT COLLBCR OP MRDICINB. 



DIVULSION OF THE SPHINCTER, AND FISSURE IN ANI. 

DwiGHT H. Murray^ under the caption, "Some Minor Rectal 
Lesions," treats of a number of ano-rectal conditions, in the Buffalo 
Medical Journal, Volume LXI, Number. IX. 

Speaking of divulsion of the sphincter muscle, he judges, from the 
statements of many physicians and patients with whom he has come in 
contact, that that procedure is not well understood. At least ten min- 
utes, on an average, should be occupied in this procedure. The muscle 
should be carefully and slowly tired out, or paralyzed, not quickly 
stretched and the muscular fibers torn. Murray has had patients who 
gave a history of rapid dilation of the sphincter, which resulted in a 
partial loss of sphincteric control. Rectal operations done after a proper 
divulsion cause much less pain, and a soreness only is complained of in 
most cases. 

Fissure in ani, at the onset is indicated by a sharp cutting, tearing or 
burning pain coming on during or after a bowel movement. Patients 
do not always know just the time it began ; they may first notice a little 
bleeding after stool, sphincteric spasm, and an increased constipation 
caused by fear of pain. The stool then may become dry and hard, 
making the fissure worse. These patients are in a very nervous condi- 
tion with many direct and reflex symptoms. Sometimes the only symp- 
tom of an anal fissure is a pain in the heel, which is often treated for 
rheumatism. 

Recent fissures, if there is no spasm of the sphincters or induration, 
may be successfully treated without operation. Orthoform applied to 
its base, followed by pure ichthyol applied every other day, is an excel- 
lent treatment for most nonoperative cases. Uncomplicated cases are 



180 EDITORIAL COMMENT. 

cured under this treatment in from two to four weeks. Operation is 
indicated in cases with hypertrophied, hard, spasmodically contracted 
sphincter, and a sentinel pile well developed. Dilation, incision and 
excision are the operative procedures, and their names are self- 
explanatory. 



EDITORIAL COMMENT. 



MEDICAL CLASSICS IN MEDICAL MEETING. 
Notwithstanding the important position which medical literature 
occupies in the domain of medicine, students are taught practically 
nothing in medical college regarding the classic works which reach 
across the centuries of medical history and chronicle the representative 
thought and practice of the various periods, while physicians are seldom 
afforded opportunity for bibliographic research in medical meeting. 
Owing to the factor of time in the career of the average practitioner, 
there is doubtful possibility of acquiring extensive concrete knowledge 
concerning the glories of the guild until the curriculum of every medical 
college includes a course in the history of medicine. The subject 
receives considerable attention in Europe, but probably not more than 
a half dozen American colleges impart instruction of this nature. 

* * * 

A feature of the Ann Arbor meeting of the First Councilor District 
Medical Society of Michigan was an exhibit by Doctor George Dock of 
some representative medical books from his private library. Lack of 
space determined the number of volumes shown to a certain extent, 
and the works selected were chosen to represent important phases of 
medical history especially in the modern period and after the rise of 
pathologic anatomy. The volumes were arranged as given below, so 
as to follow an order partly chronologic, partly topical. They were 
open to show important or interesting passages, and each volume bore 
a card with the author's name, dates and other particulars, as in the 
list below, taken from these cards. The exhibit gave a bird's-eye view 
of some of the most interesting periods of medical history. Some of 
the books, as the "Rosa anglica" and the *'Auenbrugger," are exceed- 
ingly rare. 

sK sK • 

John of Gaddesden, also called Johannes Anglicus. Died about 

1350. 

The "Doctor of Physic" of the "Canterbury Pilgrimage"; Court 
Physician. 

A copy of his "Rosa anglica," a compend of medicine. This is the 
Venice 1902 edition, erroneously called the 15 16 edition. The first 
edition was printed in 1492. 

The contents give a good idea of the medicine of six hundred years 



B 



MEDICAL CLASSICS. 181 

ago. The mdrk shows the celebrated passage regarding the use of red 
light in smallpox. 

Translation from the section on "Treatment ('Cura') of Variola:" 
"Let scarlet be taken and let him who is suffering smallpox be entirely 
wrapped in it or in some other red cloth. Thus I did when the son pf 
the illustrious King of England suffered from the smallpox. I took 
care that everything about the couch should be red and his cure was 
perfectly effected, for he was restored to health, without a trace of the 
pocks." 

Glisson, Francis. 1597-1677. (Described Glisson's capsule.) 
The first edition (1650) of his work on "Rickets," the first mono- 
graph on disease published in England, except that of Caius (died 
1563) on "Sweating Sickness," a much less thorough work. One of 
the glories of English medicine. To Glisson's description of the mor- 
bid anatomy as observed by the naked eye, subsequent writers have 
added little. 

BONETUS, ThEOPHIL. 162O-1689. 

The first (1679) edition of the "Sepulchretum anatomicum," the 
brilliant beginning of pathologic anatomy, a storehouse of the most 
important observations recorded up to that time. 

Mueller, Johannes. 1801-1885. 

"Ueber den feineren Bau und die Formen der krankhaften Gesch- 
wuelste." 1850. 

This work is all Mueller finished of a projected treatise on the 
"Histology and Classification of Tumors." It represents the first 
fruitful application of the microscope to the study of pathologic 
anatomy. One of the only two unfinished works left by this great 
genius, the master of Virchow, Helmholtz, DuBois Reymond, and the 
most important figure in the history of nineteenth century medicine. 

"Die Medicine Reform.'' 

Founded by Virchow and Leubuscher July, 1848, with the object of 
hastening reforms in university education; medical education and 
organization; care of the sick and the poor; administration of hospi- 
tals; the appointment of a Minister of Medicine for Prussia was 
demanded, and a Ministry of Public Health and Medical Laws for all 
Germany. "A Reform of Science and of Society." The journal was 
given up at the end of one year on account of the failure of the revolu- 
tion and the impossibility of a reorganization of public health, medical 
education, and the medical profession. 

Virchow, Rudolph. 1821-1902. 

First edition of the "Cellular Pathologic." 

Showing the relations of pathology and medicine to the cell doc- 
trine, and the intimate changes in the tissues and organs, on which the 
whole of modern medicine is based. No one before Virchow expressed 
the belief that the phenomena of disease, like other biologic phenomena, 
are the expressions of cellular activity, a belief that only becomes 
strengthened by the advance of knowledge. 



182 EDITORIAL COMMENT. 

First volume of the work on "Tumors," published in three volumes 
in 1863. 

The first scientific work on tumors. Based on a histogenetic classi- 
fication, it includes an exhaustive analysis of the older and even oldest 
literature, and an almost incredible investigation of actual specimens, 
macro- and microscopically. While some of the views have been 
shown by later methods to be erroneous, the work still includes many 
statements that reappear even now as new discoveries. It marked an 
epoch and will long be used as a work of reference for all points not 
requiring recent technical methods for,, their elucidation. 

Senac, Jean B. 1693-1770. 

"Traite de la Structure du Coeur, de son Action, et cetera," 1749. 

One of the most important landmarks in the history of diseases of 
the heart; especially valuable for pathologic anatomy and symptoma- 
tology. Senac was one of the most distinguished French physicians of 
the eighteenth century. 

AUENBRUGGER, LEOPOLD. I722-1809. 

First edition of the "Inventum novum," 1761, the first work on 
"Percussion." 

BicHAT, Xavier. 1771-1802. 

The first edition of the celebrated "Anatomie generale," in which 
histology, normal as well as pathologic, was first systematically studied. 
As Corvisart wrote to Napoleon, announcing Bichat's death — "No one 
before him has done so much and all so well and perfectly, in so short a 
time." 

Corvisart, J. N. 1755-1821. 

Commentaries and Translation of Auenbrugger's work on "Per- 
cussion." The first edition was printed in 1808. It saved Auenbrug- 
ger from oblivion and forced his work on the attention of men before 
auscultation was discovered. 

"Diseases of the Heart," 1806. An important book, but less so 
than if Corvisart had written it himself.- It was made up from his lec- 
tures. This, with his "Commentaries on Auenbrugger" would have 
immortalized him had he done nothing else. He was the first of the, 
modern physicians ; founder of the brilliant French school in the early 
part of the nineteenth century; first professor of medicine in the 
Medical Clinic in Paris, 1795 ; one of the founders of modem patho- 
logic anatomy ; physician to Napoleon. 

Laennec, Rene-Theophile-Hippolyte. 1781-1826. 

First edition of the "Mediate Auscultation." 

In this Laennec followed an analytic method, describing in connec- 
tion with each sign the anatomic lesion indicated. It is the outcome 
of "one of the purest and most individual discoveries ever made in the 
history of science." — (Benjamin Ward Richardson.) 

Laennec. 

Second edition, the final one by his own hands. In this, an entirely 
new work, he followed a synthetic method, with descriptions of disease 



MEDICAL CLASSICS. 183 

that proved the vast industry and talent of the author. It is a book of 
pathol(^y, as well as diagnosis, a complete treatise on diseases of the 
heart and lungs, useful even at the present day. Even the treatment, 
the weakest part, is far in advance of its time. 

Laennec. 

Showing the author's account of the discovery of mediate auscul- 
tation. (Ramadge's English edition.) 

PiORRY, P. A. 1794-1879. 

First edition (1828) of Piorry's work on "Mediate Percussion," in 
which the first advance was made in that art since the time of Auen- 
brugger, namely, the use of the pleximeter. In this, and still more in 
later works, Piorry was led astray by a search for refinements in exact 
percussion that were only slowly overcome by the work of Skoda. 

Skoda, Joseph. 1805-1881. 

First edition (1839) of the "Abhandlung ucber Perkussion und 
Auskultation." 

In this epoch-making work Skoda turned from the ultraexact 
methods of the French, who aimed at discovering specific signs for each 
disease, and laid the foundation of modern physical diagnosis, in which 
signs indicate physical conditions, which must be interpreted by the 
revelations of pathologic anatomy. Like Auenbrugger, Skoda was 
long neglected by his fellow-countrymen. The copy shown was bought 
uncut. Later, many editions were published, some of them large ones, 
and translations in several languages. 

Louis, P. C. A. 1787-1872. 

The first edition (1825) of the great work on "Phthisis." An 
unsurpassed masterpiece, said to be "the most profound exposition of 
the natural'history of a chronic disease of which the literature of any 
age or country can boast." The first work on tuberculosis in which 
the whole condition of the patient was thoroughly examined; before 
that many organs and functions in the tuberculous were never studied. 

Gerhard, William W. 1809-1872. 

"Lectures on Diseases of the Chest." 1842. 

Gerhard was a pupil of Louis, and was considered the most distin- 
guished American who studied in Paris between 1830 and 1840. The 
first who distinguished clearly between typhoid and typhus fevers 
(article published in The American Journal of the Medical Sciences, 
1835). The book shown is his principal work. Diseases of the lungs 
and the pericardium are especially well done. The treatment of pneu- 
monia is the old-fashioned one — ^bleeding, tartar emetic, et cetera. 

BowDiTCH, Henry I. 1808-1892. 

The "Young Stethoscopist" (1846) is a fine example of the work 
done by the American pupils of Louis. 

Jenner, Edward. 1749-1823. 

The second edition of the "Inquiry" into the causes and effects of 
the Variolae Vaccinae (1800), an exact reprint of the first or 1798 
edition. 



184 EDITORIAL COMMENT. 

"No book SO small has ever been talked about so much ; no book has 
been read from the original so little; no book of such dimensions has 
made the name of any author so famous ; no book has been so much 
praised at second hand." Jenner transformed a local into a universal 
belief. 

Latin translation of Jenner's first three works into Latin, made by 
Aloisius Careno, published in Vienna in 1799. An important factor 
in the dissemination of a knowledge of Jenner's discovery. 

Waterhouse, Benjamin. 1754- 1846. 

"A Prospect of Exterminating the Smallpox," 1802. 

Professor of Medicine in the Cambridge (afterwards, Harvard) 
Medical School. Introduced vaccination (1800) into the United 
States, assisted its use by his writings and by enlisting the interest of 
President Jefferson. Was called the "J^^i^^r <^f the New World." 
The copy of his book shown was given to the father of Oliver Wendell 
Holmes by Waterhouse, and later belonged to the Autocrat. It bears 
his book-plate. 

Thomson, John. 1765-1846. 

In this "Account of the Varioloid Epidemic," published in 1820, the 
author, considered the most learned physician in Scotland, demon- 
strated the identity of smallpox and varioloid, and showed that the 
latter could occur in those who had had smallpox, or had been vacci- 
nated, as well as in those who had never passed through the other dis- 
eases. He showed the unity of several varieties of variolous disease, 
and thought that chickenpox also was merely a variety of smallpox. 

Carey, Mathevv. 1760- 1839. 

"Account of the Malignant [Yellow] Fever," in Philadelphia. A 
classic of the first rank. It was written in two weeks and went through 
four editions: November 13, November 23, November 30, 1793, and 
January 16, 1794. Almost equal to DeFoe's account of the plague in 
London, but Carey's work was written in the same season, while 
DeFoe's was composed long after the plague, of which he saw little 
or nothing. 

Webster, Noah. 1758-1843. 

"A Collection of Papers on the Subject of Bilious Fevers, et cetera." 

The lexicographer got out this collection of reports by physicians, 
with comments, in 1896, before his more celebrated work on "Epidemic 
Diseases." It is chiefly interesting now in the light it throws on the 
manners and customs of the time. 

Drake, Daniel. 1785-1852. 

Equally eminent as patriot, philanthropist and medical author. 
The book on "Diseases of the Mississippi Valley" is unrivalled in the 
amount and variety of its material, and is equally remarkable for the 
charm of its style, the volume of information on diseases and their 
treatment in a time and place unique in the history of the world, and 
the glimpses of a civilization that must always be interesting to 
Americans. The Committee on Medical Literature of the American 



► 



r 



MEDICAL CLASSICS. 186 

Medical Association, in 1850, predicted that it would probably come to 
be regarded as the most valuable original work yet published in 
America. 

Blackall, John. 1771-1860. 

In his "Observations on the Nature and Cure of Dropsies," first 
published in London (1813), Blackall showed the association of dropsy 
with albuminuria, the most important contribution to renal pathology 
before the work of Bright. (Albumin had been discovered in urine, 
in 1750, by Cotunius.) 

Bright, Richard. 1789- 1858. 

In this volume of his "Reports of Medical Cases" (1827) Bright 
showed that in some cases of dropsy with albuminuria a peculiar alter- 
ation of the kidney was present. Next to Laennec's discoveries in 
thoracic disease this was perhaps the most important . discovery made 
in medicine in the first half of the nineteenth century. Before Bright's 
time examination of the kidneys was not regularly made at autopsies. 

Beaumont, William. November 21, 1785 — ^April 25, 1853. 

The first edition of the great work on "Experiments and Observa- 
tions on the Gastric Juice and the Physiology of Digestion," Pittsburgh, 
1833. Open to show one of the illustrations of the opening into the 
stomach of Alexis Saint Martin. 

Danielssen, D. C. and Boeck, W. 

"Traite de la Spedalskhed ou Elephantiasis des Grecs," 1848. 

The accurate scientific knowledge of leprosy began with this cele- 
brated work published at the expense of the Norwegian government 
and based on examinations of leper foci in all parts of Europe at a 
time when many famous physicians believed leprosy to be extinct. 

HuxHAM^ John. 1692-1768. 

A translation of the Latin edition of 1752, published in 1758 or 
1759, of the "Observations on Air and Epedemic Disease." Open at 
the celebrated account of "Slow Nervous Fever," one of the earliest 
recognizable descriptions of typhoid. He was the inventor of Hux- 
ham's Tincture of Cinchona (Comp.) 

Petit and Serres. 

In the "Traite de la Fievre Entero-mesenterique" (1813), Petit 
and Serres showed the constant presence of characteristic lesions in the 
lower part of the ileum and in the mesenteric glands; described the 
course of the lesions ; asserted they were the cause and not the effect 
of the fever and that the process was due to the introduction of a for- 
eign material. 

Louis' work on "Typhoid Fever." 

The second (1841) edition, in which the final touches were given to 
the determination of typhoid fever, the work of the American pupils of 
Louis being acknowledged. 

Smith, Nathan. 1762-1830. 

Founder and for many years faculty (sic!) of Dartmouth Medical 
College ; Professor of Medicine at Yale. 



186 EDITORIAL COMMENT. 

His "Essay on Typhous Fever" is "like a fresh breeze from the sea 
amid the dreary writing of most of his contemporaries. Never before 
had the symptoms of typhoid fever been so clearly and accurately pic- 
tured."— (Welch). "It does not follow," says the author, "that a 
patient should take medicine because he has the disease." 

Bartlett, Elisha. 1804-1855. 

"History, Diagnosis, and Treatment of Typhoid and Typhus 
Fever," 1842. 

"One of the most notable of contributions of American physicians 
to the subject. * * * written with great clearness, in logical order, 
he shows in every page an accurate acquaintance with .the literature of 
the day, and a knowledge also of that best of books, the book of nature. 
* * * One of the most successful medical works issued." — (Osier) . 

Macculloch, John. 1773-1835. 

Physician, geologist, et cetera. American reprint of the "Essay 
on Malaria," first published in 1827. 

In this work the term malaria was first introduced into medical lit- 
erature, and both its use and abuse, the latter not yet extinct as a cover 
for diagnostic ignorance, began then. The word had long been in 
popular use in Italy, and was occasionally applied by nonmedical 
English writers before Macculloch, as: Horace Walpole, 1740; Char- 
lotte Smith, 1801 ; J. Forsyth, 1813; Byron, 1821. 

CuRRiE, James. 1756-1805. 

Copy of the "Medical Reports on the Effects of Water," first pub- 
lished in 1797. Currie sought to establish three rules of practice in 
the treatment of fevers : ( i ) In the early stages cold water should be 
poured over the body. (2) In the later stages the patient should be 
bathed in tepid water. (3) In all stages abundant potations of cold 
water were recommended. This was the first large series of medical 
observations in which clinical thermometry was systematically used. 

WUNDERLICH, C. A. 1815-1877. 

"Das Verhalten der Eigenwarme in Krankheiten." (Second edition, 
1870). 

The first systematic study of clinical thermometry. Little has been 
added to it and still less changed. Scattered observations on body 
temperature were made from the time of Sanctorius (died 1636), 
especially by Boerhaave, de Haen (who showed that the temperature 
is elevated in the cold stage of fevers, and in chills), John Hunter, 
James Currie and by others. Wunderlich was the first to get accurate 
and frequent readings of the temperature, and the book is based on 
the study of twenty-five thousand cases and many millions of single 
observations. 

Brand, Ernst. 

"Die Wasserbehandlung der typhoesen Fieber." 

The second (1877) edition of the work that led to the modem 
treatment of typhoid fever by the cold bath. 



ANESTHESIA BY SCOFOLAMIN-MORPHIN 187 

ANNOTATIONS. 



A DISCOVERY REGARDING DEAD TUBERCLE BACILLI. 

The experiments of Calmette and Breton with tubercle bacilli killed 
by heat demonstrate that repeated ingestion of the organisms hastens 
the death of tuberculous subjects in similar manner as does the con- 
tinuous employment of minute doses of tuberculin. The discovery is a 
powerful argument against the use of milk obtained from animals 
which manifest even the remotest tendency toward tuberculosis. While 
the results of ingestion of dead tuberculous material are more delete- 
rious to consumptives, normal persons are by no means immune to its 
action. The authors conclude that under no circumstances should the 
milk of tuberculous animals, even though sterilized, be consumed by 
persons afflicted with consumption. 



THE CATASTROPHE ON THE COAST. * 

On the morning of April i8, San Francisco was visited by a 
frightful disaster which laid the beautiful city in ruins and rendered 
thousands of people destitute and homeless. Possibly no siesmic dis- 
turbance ever wreaked such complete distruction on the Western 
Hemisphere, and, although the list of dead, which is comparatively 
small, has probably been overestimated, the bodily ills which are 
destined to result from earthquake and holocaust will doubtless visit 
a large proportion of the population, while the number of fatalities 
indirectly attributable to the catastrophe cannot be predicted. Many 
women endured the ordeal of childbirth unassisted by medical attend- 
ance, and scores of premature births, precipitated by fright and expos- 
ure, are reported. Physicians, hampered by entire loss of medical 
equipment, labored heroically to aid suffering humanity, but with the 
dearth of food and clothing, their efforts were almost futile, and 
undoubtedly many perished before a food supply could be established. 
The country has responded grandly to the calls for monetary assist- 
ance — a sum of magnitudinous proportions having already been con- 
tributed, and if the rise of other devastated cities may be taken as a 
criterion San Francisco will shortly regain its condition of hygienic 
and esthetic equilibrium. 



SURGICAL ANESTHESIA BY SCOPOLAMIN-MORPHIN. 

While the results obtained in the domain of anesthesia have been 
varied, the operator has demonstrated wonderful achievements with 
the agents at present utilized to produce insensibility. However, the 
success of surgeons who have tested scopolamin-morphin anesthesia, 
the ease of its administration, and the cheapness of the products 



188 MEDICAL NEWS. 

bespeak the possible substitution of this anesthetic for chloroform 
and ether in the majority of operative cases. Scopolamin is obtained 
from Scapolia Japonica by extraction, having been first isolated by 
Schmidt in 1890, and first used to produce anesthesia by Schneiderlin 
about five years ago. The combination is employed by hypodermically 
injecting one-sixty- fourth of a grain of scopolamin hydrobrcmiate and 
one-sixth of a grain of morphin sulphate in fifteen minims of distilled 
water, four hours, two hours, and one hour before commencing the 
operation. Following the initial injection drowsiness ensues, and the 
second injection produces quite profound sleep. A third injection is 
sufficient to effect complete anesthesia for several hours, during which 
time the face is considerably flushed, the pulse slightly accelerated, 
respiration slow, and the skin dry and warm. While the subject may 
be aroused by loud talking or shaking, there is, during the period of 
wakefulness, -absolute insensibility to pain. In obstetric practice this 
anesthetic is pronounced free from danger to either mother or child 
and there is no report of interference with contractions or modification 
of hemorrhage. The placidity with which the injection is tolerated 
and its freedom from symptoms of vomiting, as well as thirst, together 
with other advantages already mentioned, render the medicament a 
possible succedaneum to prevalent means for effecting anesthesia. 



MEDICAL NEWS. 



ANN ARBOR MEETING OF NURSES' ASSOCIATION. 

The Michigan State Nurses' Association held its second annual 
meeting in Sarah Caswell Angell Hall, April 4, 5 and 6, 1906. James 
B. Angell, LL. D., president of the University of Michigan, delivered 
the address of welcome, and Doctor Beverly D, Harison, secretary of 
the Michigan State Board of Registration in Medicine, discoursed on 
the "State Registration of Nurses." Doctor Victor C. Vaughan, dean 
of the medical department of the University, contributed a paper on 
"Tuberculosis," while "A Neglected Field of Nursing — the County 
Almshouse," received attention from Mrs. Caroline Bartlett Crane. 
Doctor C. B. G. de Nancrede, professor of Surgery in the University, 
contributed a clinic at the hospital, which was well attended by the 
nurses. The social feature of the meeting contemplated a compli- 
mentary concert tendered by the faculty of the University School of 
Music, under the direction of Professor Albert A. Stanley, and a 
reception in Barbour Gymnasium given by the graduate nurses of Ann 
Arbor. The meeting was pronounced a profitable and pleasureable 
affair. The following officers were elected for the ensuing year: 
President, Miss Sarah E. Sly, Birmingham; first vicepresident, Mrs. 
L. E. Gretter, Harper Hospital, Detroit; second vicepresident. Miss 



THE DEMISE OF DOCTOR DOREMUS. 189 

E. L. Parker, State School for the Blind, Lansing; treasurer. Miss 
Anna M. Coleman, Saginaw General Hpspital, Saginaw; recording 
secretary, Miss Agnes Deans, Detroit; corresponding secretary, Miss 
Katherine Gifford, Grand Rapids. 



THE DEMISE OF DOCTOR DOREMUS. 

Robert Ogden Doremus^ A. M., M. D., LL. D., of New York, 
died on March 22, 1906. Gotham was his native city, and at the corner 
of Broadway and Cortlandt street he first saw light in 1842. His father 
was one of the founders of the University of the City of New York, and 
from that institution the son was graduated both in arts and medicine. 
He began his medical career as assistant to Doctor John W. Draper in the 
Chemical Laboratory of the University Medical School. Later he spent 
considerable time studying chemistry and electrometallurgy in Paris. In 
1848 he was appointed professor of chemistry in the New York College 
of Pharmacy, the laboratory of which institution he equipped con- 
jointly with Charles Townsend Harris. Doctor Doremus was one of 
the founders of the New York Medical College, of the Long Island 
College Hospital, and of Bellevue Hospital Medical College, in all of 
which he filled the chair of chemistry. From 1853 to 1861 he was pro- 
fessor of natural history at the Free Academy (now the College of the 
City of New York), and later was appointed to the chair of chemistry 
and physics in the same institution. Through his endeavor the labora- 
tory at Twenty-third street and Lexington avenue became a noted 
center of study, particularly with regard to electricity. He was the 
first toxicologic expert to be called in a murder case in New York — the 
trial of James Stephens for poisoning his wife, and his services led to 
improvements in the conduct of autopsies for the courts. For many 
years he was a well-known expert in criminal cases, and he is num- 
bered among the first of the presidents of the Medicolegal Society. He 
was a member of the New York Medical Advisory Board, and assisted 
in the organization of the Municipal Department of Health, and the 
establishment of the Bureau of Chemistry conducted in connection 
therewith. In 1871 he was appointed president of a board for the 
examination of druggists for licenses to practice pharmacy.' He inaugu- 
rated the chlorine system of disinfecting ships, and thus obviated the 
necessity for prolonged detentions at quarantine. The important inven- 
tion of granulated, compressed gunpowder contemplates another of 
his achievements. This product was employed by the French in the 
Franco-Prussian War, its power greatly exceeding that of ordinary 
gunpowder. The excavation of Mont Cenis tunnel was also wrought 
by. this product. Doctor Doremus was interested in every department 
of culture, and was especially prominent in musical circles, being one 
of the founders of the Philharmonic Society, of which he likewise 
officiated as president for some time. Several years ago he celebrated 
his golden wedding, but since then his wife has died, and four children 
survive him, Professor Charles A. Doremus being the oldest. 



190 MEDICAL NEWS. 

MINOR INTELLIGENCE. 

An epidemic of smallpox is threatened in the penitentiary located 
at Lansing, Kansas, four convicts having recently been stricken with 
the disease. 

The establishment of a state tuberculosis sanatorium in Iowa has 
been facilitated by the passage of a bill in the legislature appropriating 
$50,000 for the purpose. 

At the recent Pittsburg meeting of the American Association of 
Medical Colleges, the medical department of Oklahoma University 
was admitted to membership. 

Typhoid fever is epidemic in Pittsburg, more than four hundred 
cases having thus far been admitted to the hospitals, besides the hun- 
dreds of other cases scattered throughout the city. 

The sum of $50,000 has been provided by Mrs. Louisa N. BuUard 
for the establishment of a Chair of Neuropathology at Harvard 
University. The bequest is made as a memorial to the husband of 
the donor, William Story Bullard. 

Saint Luke's Hospital, New York, has been enriched to the 
extent of $15,000 by a bequest of Mrs. Sarah A. Sands, whose death 
occurred recently. The sum will be utilized to endow three beds in 
memory of the donor's husband, Abraham B. Sands. 

The Prussian Minister of Railways has inaugurated a novelty in 
the method of transporting sick persons in railway coaches. Suitable 
stretchers will be admitted to third-class compartments, two third-class 
fares being paid for patient and stretcher and one for the attendant. 

Experiments announced from the Edinburgh University research 
laboratory are to the effect that trypsin injected into a cancerous mass 
will effect its absorption, but since the agent has only been employed 
on rodents, its practical value in human subjects remains undetermined. 

Doctor Johann Flintermann was recently tendered a testimonial 
dinner by the Detroit Club in commemoration of the fortieth anniver- 
sary of his advent into medical practice. Doctor Flintermann received 
his medical degree from the University of Gottingen in 1864, and two 
years later he located in Detroit. 

A FREE tuberculosis clinic, to be in charge of Doctor Victor C. 
Vaughan, was recently opened in the Detroit Board of Health building. 
It is estimated 'that there is an average of one death a day in Detroit 
from this disease, and the purpose of the clinic is to instruct subjects 
how to care for themselves and prevent the spread of contagion. 

Doctor Frank William Smithies has been appointed demon- 
strator of medicine in the University of Michigan, to succeed Doctor 
Roger S. Morris, who accepted a position in Johns Hopkins Hospital. 
Doctor Smithies is an Ann Arbor graduate, and since receiving his 
degree has been connected in a teaching capacity with the University 
of Chicago. 



EPITOME OF THE PRACTICE OF MEDICINE. 191 

Fourteen women physicians of Detroit recently organized a society 
whose membership is limited exclusively to women practitioners. It 
is designated the Women's Academy of Medicine, and is the third of 
its kind in the country, the others being located at New York City and 
Rochester, New York. Women physicians in Michigan who are mem- 
bers of their county society are eligible to membership in the new 
guild. The following officers were elected for the ensuing year: 
President, Doctor Lucy J. Utter; vicepresident. Doctor Mary G. 
Haskins; secretary. Doctor Anna Starring; treasurer. Doctor Minta 
P. Kemp; councilors, Doctors Florence Huson, Louise Rosenthal- 
Thompson and Isabella Holdom. 

On April 2 a free clinic, to be known as the German Polyclinic, 
was established in connection with Grace Hospital, Detroit. The new 
institution will be essentially German in character, none but physicians 
of Teutonic extraction being eligible for official positions, although 
treatment will be tendered to afflicted regardless of race or creed. 
Doctors Herman Kiefer and Ernest W. Haas have been elevated 
respectively to the presidency and secretaryship, and the various chairs 
will be occupied as follows: Children's diseases, Doctors Charles G. 
Jennings and Guy L. Kiefer ; general medicine : attending staff. Doctors 
Ernest W. Haas and August Gorenflo; consulting staff, Doctors Carl 
Bonning and Herman Kiefer; diseases of the eye and ear, Doctor 
Louis J. Hirschman ; diseases of women. Doctor James A. MacMillan ; 
nose and throat, Doctor Fred J. Clippert; diseases of the digestive 
organs. Doctor George W. Wagner; pathologist, Doctor Edward H. 
Hay ward; surgery. Doctors Johnston B. Kennedy and George H. 
Palmerlee. 



RECENT LITERATURE- 



REVIEWS. 



EPITOME OF THE PRACTICE OF MEDICINE.* 
This little manual is indeed an excellent guide so far as it goes. It 
is intended to be only an epitome. There are men who oppose the use of 
these contractions — good men; and there are men who think they are 
of great use to the student and practitioner who are also good men. 
These compendiums cannot help being good books because they are 
copied from good books. Usually they are condensed rearrangements 
of Osier's, Anders', or some other standard work, altered just enough 
to make the reading a little different, with the definitions a bit modified. 
Even those who oppose them enjoy perusing them. They are some- 
times refreshing, and if one should question closely he will probably 



192 RECENT LITERATURE. 

find that these men are fond of some similar little book, the only differ- 
ence being that it is published in another language. We find a few 
mistakes but they can easily be excused on the ground of "first edition." 
We think that many of these abbreviated books have a place, and many 
of them fill a long felt want. This is one of them. Jt is thoroughly 
up-to-date. 

*A Manual for Students and Practitioners. By Hughes Dayton, 
M. D., Principal to the Class in Medicine, New York Hospital, Out- 
Patient Department; Clinical Assistant in Medicine, Vanderbilt Clinic, 
College of Physicians and Surgeons, Columbia University. In one 
i2mo volume of 324 pages. Cloth, $1.00, net. Lea Brothers & Com- 
pany, Publishers, Philadelphia and New York, 1905. 



A LABORATORY MANUAL OF PHYSIOLOGICAL 
CHEMISTRY.* 

Doctor Rockwood's laboratory manual is admirably adapted to the 
needs of the student of physiological chemistry. Only the most impor- 
tant illustrative experiments are given in large type and they are not 
too many and are well chosen. It has the advantage over books that 
are filled with interrogations in that while it does not fail to interrogate, 
it intelligently answers, thus making it of service to the student and of 
inestimable value to the busy physician who wants an immediate reply 
to his query. Here and there are additional leaves inserted for notes. 
Altogether the book is a very valuable one, and can be especially recom- 
mended to those who wish to begin the study of, or review the sub- 
ject. D. M. c. 

*By Elbert W. Rockwood, M. D., Ph. D., Professor of Chemistry 
and Toxicology and Head of the Department of Chemistry in the 
University of Iowa, et cetera. Second edition, revised and enlarged. 
With one colored plate and three plates of microscopic preparations. 
Large i2mo, 229 pages, extra cloth. Price, $1.00, net. F. A. Davis 
Company, Publishers, 1914 Cherry street, Philadelphia, Pennsylvania. 



PROGRESSIVE MEDICINE. 

Progressive Medicine for December is full of its usual amount of 
the world's best medical literature. We have praised the merits of 
this publication so many times that it seems unnecessary to say more. 
It is one of our most welcome visitors. It is impossible to see how it 
could be improved. d. m. c. 

*A Quarterly Digest of Advances, Discoveries, and Improvements 
in the Medical and Surgical Sciences. Edited by Hobart Amory Hare, 
M. D., Professor of Materia Medica and Therapeutics in the Jefferson 
Medical College of Philadelphia. Lea Brothers & Company, Pub- 
lishers, Philadelphia and New York. 



A PROFESSIONAL MEDICAL JOURNAL. 



VOLUME XXVIII. MAY, 1906. NUMBER V. 



ORIGINAL ARTICLES. 



MEMOIRS. 



MODERN SKIAGRAPHIC TECHNIQUE.* 

By VERNON J. WILLEY, A. M., Ann Arbor, Michigan. 

DIRSCTOR OF THB UNIVBRSITT HOSPITAL ROSNTGBN LABORATORY. 

It is undoubtedly true that the technique employed in making 
Roentgen radiographs is, with many who make use of the Roentgen 
rays in diagnosis, largely the result of habit and convenience. It is 
with most of us, largely a personal problem. It is also true that radiog- 
raphy is largely an art, and partakes but little of systematic scientific 
application. Yet there are certain fundamental principles, recognized 
by many, which are preparing the way for a logically developed system. 

What is meant by a good radiograph? What should it show? 
How shall we judge whether or not it is technically correct? First of 
all it is well to be clear on one point : a radiograph is not a photograph. 
It does not represent by its shades and shadows, the real object. It 
is a record of the different densities encountered by the Roentgen rays 
in their passage through a body made up of materials presenting differ- 
ent degrees of obstruction to the passage of the rays. A photograph 
is a record of impressions made by rays of light of various degrees of 
intensity, reflected from the object to the sensitive plate. There may 
be no suggestion of the density of the object photographed. The pho- 
tograph represents the real object, and is easy of recognition. The 
radiograph is a record of the densities of the different parts or organs 
through which the rays pass to reach the sensitive plate, and may or 
may not be easy of recognition; in not a few instances it requires a 
radiographically trained eye for its correct interpretation. A good 
radiograph is one which, first of all, renders a truthful record of these 
densities, and is simple and easy of interpretation. Negatives must 

♦Read at the Ann Arbor meeting of the First Councilor District Medical 
Society, December 22, 1905. 



194 ORIGINAL ARTICLES. 

be produced showing the greatest possible contrast between tissues of 
different density. The differentiation must be sharp and clean cut, the 
negative clear, clean, and free from iog or haziness. The simplest 
method of judging of the value of the radiograph as to whether it shows 
the presence or absence of pathological conditions, is, of course, com- 
parison with a normal radiograph. The anatomical structures which 
show in the normal radiograph should be carefully studied and com- 
pared with the corresponding structures of the radiograph in which 
pathological structures may be revealed. Theoretically one should be 
able to show by a radiograph any pathological condition involving a 
marked change in density of the involved tissues. Practically we are 
able to realize this to a very satisfactory degree, but it is useless to 
place much reliance upon a skiagraph which has not truthfully recorded 
normal structures which differ more in density than the change from 
normal to pathological. 

The production of a radiograph fulfilling the necessary conditions 
depends upon — 

First, properly selected electrical apparatus kept in perfect working 
order. 

Second, properly selected and properly excited vacuum tubes. 

Third, suitable accessories for diaphragming the rays, and for 
immobilizing the part radiographed, and 

Fourth, reliable sensitive plates or films, followed Ky correct and 
special photographic technique. 

The electrical apparatus, static machine, induction coil, or high 
tension transformer should be one with which the operator is thor- 
oughly familiar. If he expects to progress further than the elements 
of the subject, embraced in the radiography of extremeties, he will 
require an induction coil capable of delivering at least a nine-inch solid 
flame, and preferably one delivering more than a fourteen-inch flame. 
The apparatus must be so adjusted, and supplied with controlling 
rheostat and variable inductance, as to respond at once to his varied 
requirements. If he is to attempt rapid w^ork, the primary circuit must 
be broken by an electrolytic interrupter preferably of the Wehnelt type. 
This invention of Wehnelt has done more than any one thing to make 
possible the extensive use of Roentgen rays in diagnosis. The Wehnelt 
interrupter is simple of construction, works equally well on alternating 
and direct currents, and the operator who makes his own and keeps 
it in repair has mastered a large percentage of the instrumental troubles 
which are likely to confront him. 

The fundamental requisite of the Roentgen tube is that its rays 
must penetrate the tissues to be radiographed. The thicker the tissues 
or the greater the density the greater must be the penetration. The 
proper working of the tube is exhibited by the hemisphere of the tube 
in front of, or anterior to the face of the anode, fluorescing brilliantly, 
clearly, and steadily. The hemisphere of the tube back of the anode 
should be quite dark, without fluorescence, and without irregular fluor- 



MODERN SKIAGRAPHIC TECHNIQUE. 195 

escent rings. This latter condition is important, even though at times 
difficult of accomplishment. 

The penetration of the tube is a perfectly measurable quantity, and 
its actual measurement is an important advance in bringing about 
improvement in and uniformity of methods. 

A simple form of penetrometer may be made by a combination of 
the Renoist i^enetrometer and the aluminum window penetrometer. 
Cylinders of aluminum, of two, four, et cetera, to sixteen millimeters in 
thickness, and about eight millimeters in diameter, are cut from a rod 
of aluminum, and the eight cylinders set in apertures in lead, the first 
four in lead one-half millimeter thick, and the remaining four, ten to 
sixteen millimeters thick, set in apertures of a strip of lead one milli- 
meter thick. The device is then glued to a thin board, and placed in 
front of a small fluoroscope. Tubes whose rays penetrate freely the 
first four or five aluminum cylinders, and the one-half millimeter lead 
strip not at all, are "soft" tubes, or "low tension" tubes, although the 
latter term is a misnomer. Tubes whose rays penetrate all the cylinders 
and the one-half millimeter lead strip to some extent, are ''hard" tubes, 
or "high tension" tubes. The terms hard and soft are purely relative, 
having to do only with the penetration of the rays. 

The Walter penetrometer is the international standard. Soft tubes 
penetrate four or less platinum windows, while hard tubes penetrate 
from five to seven windows. Tubes are now designated as Walter 
4. 5. 6 or 7. according to their penetration. 

Besides being of correct penetrating power the tube must be capable 
of enduring a heavy current (amperage) for the required time of 
exposure, that is one-half second to six or eight minutes, without over- 
heating, lowering of vacuum and lessening in penetration. It should 
be one which emits a large percentage of direct rays, supposedly from 
the focal point on the anode, and a small percentage of indirect rays, 
or rays from the walls of the tube, or at least not from the focal point 
on the anode. If a hard tube be used, it is preferable to use one which 
has been aged or seasoned to the degree where it will emit rays of a 
nearly homogeneous character, rather than a mixture of rays varying 
from those of extreme softness to those of extreme hardness. The 
tube should be one having a high efficiency as a transformer of elec- 
trical energy into Roentgen rays. 

At present there is no simple and satisfactory method of measuring 
directly the volume of rays given off by a Roentgen tube. The nearest 
approach to it is the measurement of a function w^hich is proportional 
to it. namely, the current exciting the tube. A milliamperemeter con- 
structed to be used in series with the tube indicates, for a given tube 
excited by the same apparatus, a current strength proportional to the 
radiant output of the tube. Or more strictly speaking, the volume 
of rays is proportional to the square of the current strength, provided 
the resistance of the tube and the penetration remains constant. This 
is very nearly realized in practice, radiographically, for, in exposing a 



196 ORIGINAL ARTICLES. 

Structure for radiographic purposes, if two milliamperes through the 
tube requires an exposure of sixteen seconds, four milliamperes requires 
not eight seconds, but only about four, and a radiograph may be made 
of the part exposed in one and one-half to two seconds if we can excite 
it by six milliamperes. It is possible to secure a good radic^raph of 
a one hundred fifty pound man in one second, by using a Walter 6 
tube, excited by six milliamperes, from an induction coil actuated by an 
electrolytic interrupter. 

With reference to the penetration of tubes employed in radiography, 
Roentgenologists are divided more or less sharply, into two schools, 
advocates of soft tube technique, with attendant long exposures, employ- 
ing Walter 3 to 5 tubes, and users of hard tubes, Walter 5 to 7, requiring 
exposures of one-half second to ten seconds, for radiographing any 
part of the body, while the Walter 3, 4, or 5 tube requires from twenty 
seconds to six minutes exposure to do the same work. So far as I 
know, there are no radic^raphers who are equally skilled in the use of 
both hard and soft tubes. 

At first thought it might seem that the advantages are all with the 
use of the Walter 5, 6, and 7 tubes. This, however, is not true, as soft 
tubes, Walter 5 or less, possess the undeniable advantage of giving 
greater detail and contrast in soft parts, especially radiography of abdo- 
men and chest, than the average hard tube. In other words, we are 
able, by using the soft tube, to record upon the plate more marked 
differentiation between tissues differing but slightly in density. In 
addition the likelihood of overexposing the plate is very much less than 
when using the hard tube. On the other hand there is the greatest 
danger of "burning" — it is the rays of slight penetration which produce 
changes in the integument. 

The difficulty of immobilizing the patient during the long exposure, 
the absolute impossibility of radiographing lungs and abdomen during 
suspended respiration, and the numerous failures in attempted radio- 
graphy of small children who cannot be kept from moving during the 
exposure, are drawbacks which have from time to time annoyed and 
discouraged the user oi the soft tube. The greatest trouble of all, 
however, is the rapid heating of the soft tube under heavy current 
excitation, its quickly lowering vacuum following this, and the resulting 
lessening of the penetration rendering the tube for the time absolutely 
worthless for radiographic purposes. 

With the use of the hard tube there is extreme improbability of 
producing a dermatitis, even if a dozen radiographs be taken of the 
same patient, the same day. It is also possible to secure immobility 
of all parts of the body. One can radiograph either chest or abdomen 
during suspended respiration, and avoid all blurring of shadow-detail 
due to respiratory movements. With a properly seasoned old Roentgen 
tube we may pass a heavy current through it for a dozen consecutive 
radiographs without materially interfering with its penetration. Such 
a tube also possesses a higher efficiency as a transformer of electrical 



MODERN SKIAGRAPHIC TECHNIQUE. 197 

energy into Roentgen rays. There are some important changes taking 
place during the life of a tube, which all experienced radiographers have 
noted. The new tube is naturally soft. It produces really good radio- 
graphs only when in this condition. Its vacuum is very unstable. It 
will heat and run down during exposure, and rise a little higher in 
vacuum on cooling. After a time it reaches a degree of hardness 
where its rays freely penetrate the bones. It has reached a penetration 
of Walter 6 or 7, but it possesses poor definition; that is, the output 
of direct rays may be as low as twenty per cent of the energy absorbed, 
while the indirect rays may be as great as forty to sixty per cent, the 
balance of the energy being transformed into heat. Upon lov^ering 
the vacuum successively, it will naturally run longer, without excessive 
heating, and not rise as rapidly upon cooling. It is approaching a stage 
where its vacuum is more nearly stable. In the course of a year, if the 
tube be used for a short time daily, it has undergone remarkable 
changes. The glass of the anterior hemisphere becomes darkened. 
The glass annealed, the vacuum more constant, it will stand a heavy 
current without heating, and instead of fluorescing a greenish-yellow 
or an olive green, it will fluoresce a sunflower-yellow, a yellow almost 
as pure as the sodium light. Its penetration is about Walter 6. It 
gives beautiful definition; the medullary canal of the ulna is clearly 
defined by the fluoroscope. It has become a seasoned tube. Its output 
of direct rays may rise as high as seventy per cent of the output of 
radiant energy, and the rays seem to be much more nearly homo- 
geneous in quality than those from a Walter 6 new tube. Such a tube 
is worth many times the value of a new tube for radiographic purposes. 
It is better to save a well seasoned old tube for the more difficult work, 
such as radiography of skull, chest, renal and biliary calculi. 

The use of the diaphragm for cutting off the indirect rays is of the 
greatest service, particularly when using a comparatively new hard 
tube. A scientifically constructed diaphragm, with its accompanying 
compression cylinder or compression ring is a necessary accessory to 
every fully-equipped radiographic armamentarium. 

In the construction of these compression diaphragh cylinders some 
deplorable mistakes have been made which appear to be due to a lack 
of knowledge of the fundamental principles of radiant energy. When 
Roentgen rays or any other form of radiant energy pass from one 
medium to another of different density, the particles of the second 
medium act as secondary centres for the production of secondary radia- 
tions, according to the principle of Huygens. Hence if we would 
avoid the secondary rays from the inside of the cylinder, we must 
make our diaphragm at the top of the cylinder the truncated portion of 
a cone whose apex is the focal point on the anode, and whose base is 
coincident with the periphery of the bottom of the cylinder. We are 
indebted to Albers Shonburg for the compression diaphragm cylinder 
and to Dessauer for first calling attention to the correct principles of 
construction of ^ch apparatus. 



198 



ORIGINAL ARTICLtrS. 



It is perfectly possible to make a radiograph by means of these 
secondary .i--rays generated from the inside of the cylinder of improper 
construction. The direct rays may be intercepted by a thick lead disc, 
ami the secondary .t--rays, s (Figure I), allowed to pass through the 
structure to be radiographed. On the other hand their production may 
be eliminated by the proper diaphragm, while at the same time mini- 
mizing the transmission of indirect radiations from the tube. The 
accompanying diagram (Figure I) illustrates, in the left hand half of the 
figure, a cylinder of improper construction, with its indirect and sec- 
ondary rays, while the right half shows how these may be eliminated 
by the diaphragm of correct aperture. A diaphragm apparatus of nearly 
universal application may be constructed by covering a suitable-sized 




FiGURK I. — (d) Apex of cone of direct rays, (i) Indirect rays from walls of tube, (s) Sec"^ 
ondary rays from cylinder walls. 

board or fiber support with a layer of a mixture of putty and mercurous 
oxide on the side next the tube. A convenient aperture, of from five 
to eight centimeters, is left in the center. This diaphragm, being a non- 
conductor, nonmagnetic, and noninductive, may be placed in direct 
contact with the tube. Suitable lead diaphragms may be employed for 
further limiting the field covered by the rays, and two or more rings 
may be detached to the under side of the diaphragm for purposes of 
compression or immobilization. The diagram (Figure II) will make 
clear its construction. 

The compression rings of seven and one-half and ten inches in 
diameter, in addition to a five and one-half inch cylinder, will fulfill 
about all of the requirements demanded of such apparatus by the radiog- 
rapher. 

Lastly, I wish to mention briefly the photographic technique. The 



MODERN SKIAGRAPllIC TECHNIQUE. 



109 



radiograph is a special negative. It should possess strong and emphatic 
contrasts. Two of the most important factors in the production of the 
best grade of radiographs are the correct exposure, and the correct 
developmental technique. The physician who exposes his plates, and 
then passes them on to a portrait or landscape photographer for devel- 
opment, will not obtain the highest grade of work, until both learn 
by experience the important difference between a landscape or portrait 
negative, and a radiographic negative. A different developing formula 
and a different duration of development are essential. Especially is 
this true if the hard tube technique be employed. 

In conclusion, I may say that while a great deal depends upon the 
apparatus and its correct management, there is also the personal factor 




Figure II. — (a) Layer of putty and mercurous oxide. (b) Wood or fiber support, 
(c) Metal diaphragm, (d) Cone of direct rays. 

of the radiographer. If he would succeed he must train his judgment 
by keeping a careful record of all exposures, and making careful 
measurements of all the factors which he employs, which are capable 
of measurement. It is only by persistent systematic training that he 
can ever hope to be able either to duplicate his best results or to place 
his work on a scientific basis. 

The use of the Roentgen rays in diagnosis has made remarkable 
strides since the presentation of Roentgen's paper upon its discovery, 
ten years ago this month. If the next five years are as fruitful in 



200 ORIGINAL ARTICLES. 

progress as the last five, even the skeptics will be compelled to admit 
that this new diagnostic and therapeutic agent is the most useful, if 
not the most interesting, contribution that the science of Physics has 
ever made to the science of Medicine. 



A SURGICAL PILGRIMAGE TO ARKANSAS. 
By HAL C. WYMAN. M. S., M. D.. Detroit, Michigan. 

PROPBSSOIl or SURGBKY IN THB MICHIGAN COLLBGB OP MBDICINB AND SURGBRY. 

Arkansas was settled originally by people from Tennessee, and 
consequently the Arkansans maintain the customs and trend of thought 
common to the Tennesseeans. In the early days of that state, there 
was a law to the effect that if a negro went about the country prac- 
ticing medicine or healing the sick, he was punished by a drubbing not 
to exceed twenty-five lashes, while his master, if he were cognizant of 
the fact, was liable to a fine. The people of Tennessee would not allow 
any "free" colored person to remain in their state more than twenty 
days, and slaves were never permitted to assemble in unusual numbers, 
without the expressed consent of their owners. In Arkansas now 
there is a State Medical Society composed entirely of colored physi- 
cians. I met the president. Doctor Claude M. Wade, during a recent 
sojourn in Hot Springs. I found him a regular graduate in medicine, 
practicing his art in accordance with the laws of the state. He is at 
the head of the Saint Pythias Sanitarium in that city, an institution 
with twenty beds, which takes patients of any color. The medical law 
of Arkansas recognizes all the "pathies." If a man would practice 
regular medicine, be he white or colored, he must appear before a 
board of regular physicians, exhibit his diploma, and pass a satisfactory 
examination. If he is an eclectic, as many of them are, he is required 
to appear before a board of that persuasion, exhibit his diploma, and 
give written evidence of qualification in order to gain the right to 
practice. 

Hot Springs, the mecca of many medical pilgrims like myself, is 
located in Garland county, and after having visited all its sanitariums, 
including the splendid institution of Doctors Holland and Laws, I 
visited the County institution about four miles distant from the city, 
over West Mountain. Judge of my surprise, after finding the color 
Hne in the city so distinctly drawn as to require two separate medical 
societies, at finding the County Poor House containing inmates, both 
white and colored, without separate buildings. In one little building, 
called the "jail," or *'crazy house," I found two helpless melancholic 
female patients in the midst of the most wretched filth and fetor, in 
cells adjacent to three men afflicted with acute mania, one of whom 
was colored. One of these poor women had stripped herself of cloth- 
ing, torn her bedding to bits, and during the recent cold nights had 
her feet frozen, so that great sloughs of skin and fascia were now 
adding to her discomforts. The crazy negro wanted to kill somebody 



A SURGICAL PILGRIMAGE TO ARKANSAS. 201 

all the while. One of the men had epileptic seizures two or three times 
a day. The other woman shrieked and moaned almost incessantly, 
begging to be taken to her home. A' physician comes out from Hot 
Springs at intervals to visit these unfortunate people, instruct the man- 
I ager in the art of cleaning the cells, and making the occupants comfort- 

i able. Other of the inmates, irrespective of color, were wandering 

^ about the little frame building in all stages of mental debility, from 

low grade idiocy to the lighter forms of senile and moral imbecility. 
I had a talk with Doctor Joseph W. Shaw, at his office in Buckville, 
about twenty-five miles from Hot Springs, about the people I saw in 
the County Poor House, and he said they ought to be sent to the 
asylum at Little Rock. He had served several terms as a member of 
the legislature from Montgomery county, and his son. Doctor Argus 
D. Shaw, of Hot Springs, was county physician at the Poor House. 
Doctor Shaw is a fair type of the better qualified rural practitioners of 
Arkansas. He has been in practice since the close of the Civil War 
and is thoroughly familiar with the law governing the care and med- 
ical treatment of pauper and insane persons. He told me that it was 
the custom to let the paupers out to the highest bidder, that is, a man 
who would agree to keep the pauper in his own home for the lowest 
figure per annum would get the patients ; and with the insane, unless 
the malady was pronounced, the same rule obtained. But when the 
i case was at all severe, the person was tfiken before the county judge, 

and examined, the testimony of the physician in attendance being taken 
and the patient sent to the asylum at Little Rock. I could not learn 
of any very careful discriminating examinations to determine the likeli- 
hood of this or that operation or treatment being useful to the patient. 
The county judge does the examining and the physician merely deter- 
mines the question of insanity, basing his conclusions on the disposition 
of the patient, without regard for the pathology, surgery or therapeutics 
in the case. Doctor Shaw has another son practicing with him, and 
together they do most of the practice within a radius of twelve or 
fifteen miles, riding the rough mountain trails, and fording the moun- 
tain torrents on horseback. They have some malarial fever and Doctor 
Shaw, elder, is not a believer in all phases of the mosquito theory. 
He doubts whether the mosquito is the only vehicle for the conveyance 
of the Plasmodium malariae. There are occasional cases of appendicitis 
occurring in the mountain regions remote from the city hospitals and 
surgical sanitariums of Hot Springs and other cities, wherein the rural 
practitioner does his own operating, and in more than many instances 
I found physicians splendidly equipped with a knowledge of the serious 
' phases of abdominal surgery. The city physicians of Arkansas are 

reluctant to go into the country, for the reason that the people in the 
fastnesses of the Ozarks, though happy, are often poos, consequently 
I the doctor on this or that creek, or in this or that hollow, as the country 

is spoken of, must do his serious surgery himself. At the little town 
of Harrison in the midst of a most rugged country teaming with 



202 ORIGINAL ARTICLES. 

I^ople living in the easy way of the Arkansan, there is a doctor whose 
fame keeps him busy and brings him all sorts of surgical cases within 
a radius of from fifty to sixty miles. His results in hernia, appendi- 
citis, and ovariotomy are just as good as those obtained by any man. 
The pure air, the fine water of the mountain districts, as well as the 
skill of the operator are strong factors in the recovery of patients. 

The medical visitor at Hot Springs is not surprised at the character 
of ills observed on the much frequented streets. One of the grandest 
clinics in the world may be observed passing in an almost endless pro- 
cession through the principal streets and about the springs. Just why 
the hot water emanating from the earth at this place should possess 
such great value in the cure of many chronic ills is difficult to say, but 
certainly it has the power of attenuating and eliminating almost any 
poison contained in the system of those who drink enough of it. It 
increases voluminously the excretory functions of the skin, kidneys, 
and bowels. The Government controls the sources of the water, there 
being a reservation maintained by the United States. Entrance to this 
reserve is indicated by two huge gate-posts, surmounted by bronze 
eagles, and illuminated with the name of "Hoke Smith,'* who happened 
to be Secretary of the Interior when certain improvements on the Gov- 
ernment Reserve were made. I cannot but consider the disfigurement 
of these two splendid gate-posts with the name of Hoke Smith cut upon 
them a matter of very bad taste, but since this officer was one who 
cleaned out the **old mud hole" — the ''^old ral hole," as it was called by 
countless thousands, who bathed in it and were cured of their specific 
ailments — and substituted for it the present free bath-house, where any- 
one who registers his name, may receive a bath in a clean porcelain 
tub and cement pool, free of charge, I do not see why the medical visitor 
at Hot Springs may not pass judgment on matter of taste and public 
policy. It is not considered in good form for officers of the United 
States government to have their names cut in the solid stone to com- 
memorate any of their acts performed as the servants of the people. 
The profession in Hot Springs is in a state of turmoil, into which they 
have dragged the courts, over the matter of drumming for patients. 
A X'isitors' Protective League exists among the physicians, and its 
function is to ascertain and endeavor to stop the practice. The United 
States Government has jurisdiction over the water coming out of the 
Government mountain on the reservation and will allow only those 
whom it examines and registers as competent, qualified physicians to 
prescribe the water for their patients. There are a great many physi- 
cians in Hot Springs who are not permitted to use the water of these 
springs in their practice. 

Surgery in Hot Springs is not practiced very extensively, as com- 
paratively few of the horde of invalids coming here present operable 
cases. There are a number of sanitariums with neatly equipped oper- 
ating rooms, where all sorts of operations may be performed. There 
are numbers of men skilled in the surgical arts, who are ready at any 



A SURGICAL PILGRIMAGE TO ARKANSAS. 203 

hour of the day or night to perform any operation needful for the relief 
of human suffering, and there are plenty of trained nurses, too, who 
like surgical cases, but relatively few operations are perfonned. Hot 
Springs is not a surgical center, it is a place where drugs are tested 
to their full value and where the healing powers of the hot waters of 
the earth exert their greatest efficiency. A curious custom prevails 
among the physicians in regard to charges. The consultation fee, or 
first visit of a patient to a doctor, is five dollars. He is then informed 
that the subsequent charges will be twenty-five dollars per month, 
invariably in advance, and no matter what the disease, the patient 
may come to the doctor's office as often as he thinks the condition 
demands attention. I was told that this rule in regard to charges and 
custom in regard to visits was established very early in the history of 
the springs, that it works admirably, and that all the patients sitting 
in the doctors' waiting-rooms represent pay patients, on the twenty- 
five-dollars-a-month plan. The doctors are located, mostly, on one 
street, facing the Government Reservation. Generally their offices are 
over the stores, and the patient must climb a long flight of stairs. The 
doctor, in prescribing baths, writes his instructions, which are carried 
out to the letter in the bath-houses on the reservation using the hot 
waters. I saw some very interesting cases of necrosis of the bones of 
the face, nasal bones, grouped about the hot springs inhaling warm 
vapor which rises from the waters in the early morning. Many of 
these poor people were in need of surgery, to cut away the diseased 
bone. 

The country around about Hot Springs is mountainous, the town 
being situated in the foot-hills of the Ozarks. The drainage of the 
country is through the Ouchita river, a beautiful stream heading up 
near Indian Territory and Arkansas. The hills are covered with 
splendid forests of pine, oak, ash, gum, and hickory. In many of the 
hills gold has been found. In almost any direction you may travel on 
horseback you will find extinct mining camps, where dilapidated build- 
ings and rusted-out machinery are to be seen. The region for twenty- 
five miles about Hot Springs is quite thickly populated, notwithstanding 
the forests, and nearly every section of land has one or two families 
living upon, it in neat little log cabins with plenty of children whom I 
found invariably healthy and happy, subsisting largely on a diet of 
corn meal which is grown in a patch of rarely more than four or five 
acres (usually the only cultivated ground about the homestead), and 
the delicious meat of the long-nosed, half-wild, razor-back pig, which 
thrives the year around on roots and nuts. Once iyi awhile a church 
or a school-house is found, and on the streams occasionally a mill with 
the old French burrs for grinding corn, which preceded the introduction 
of the modern roller process of milling grain. The simple diet of the 
native Arkansans who settled this country in the thirties largely, main- 
tains a sturdy class of citizens. I would not have you think that hog 
and hominy is the sole diet of these people. The mills just mentioned 



204 ORIGINAL ARTICLES. 

make splendid meal of the pure hard corn, which thrives everywhere 
in the country around Hot Springs. This meal contains all the nutri- 
tive elements of the grain, and is quite different from the product of our 
northern mills. The people have cattle and use milk and butter to a 
moderate extent. They are not, however, well posted in the science of 
dairying, and I fear the rugged little cattle are not profitable producers 
of fat. They are so numerous in the country I traveled over that they 
have devoured all the canebrake which used to fill the valleys and low 
places along the mountain streams. Their hides are a source of income 
to the mountain farmer, or cracker, as he is sometimes called. Inquiry 
revealed an occasional case of anthrax and progressive purulent infec- 
tion of the hands of persons who had been handling hides of cattle 
found dead in the woods. I could not learn that deaths were due to 
tuberculosis among the cattle, but believe that they were the result 
of insufficient food during the winter period, a little shorter though 
much less severe, than that of Michigan. The people are beginning 
to learn the value of poultry as a food, and as a means of increasing 
the family revenue. I found fine chickens about every homestead, and 
fresh eggs and fresh fowl supplement the pork and corn meal diet I 
have been writing about. In the little field about the house, are com- * 
monly grown a few potatoes of the Irish variety, and a larger quantity 
of sweet potatoes, which are secured for use through the winter season. 
Cabbage, turnips, cauliflower, tomatoes and all sorts of wild fruits and 
berries are valuable adjuvants to the foods I have just mentioned. 
The total cost of living on a good wholesome diet in the country round 
about Hot Springs is surely not very high. Corn is worth fifty-five 
cents a bushel shelled, a bushel loses one-eighth in the process of grind- 
ing, and will feed, when made into meal, a family of five persons three 
weeks. That is only two and one-half cents per day. The pork, dressed, 
is worth six dollars a hundred, and a family of five persons will eat 
three hundred sixty-five pounds a year. That is about six cents a day, 
making the total cost of living for a family of five persons about eight 
cents a day. That this diet, inexpensive as it is, is sufficient for good 
sound health and mental vigor is amply attested by the freedom of the 
people from tuberculous infections, chronic anemia, or neuritis. 

Not a small part of the curative value of a sojourn at Hot Springs 
is due to frequent excursions, either on foot or on horseback, into the 
mountainous country round about the town. The better qualified phy- 
sicians nowadays advise these excursions as a part of routine treatment 
accompanying the baths, and they are of fully as much value as the 
massage and inunctions liberally practiced. I could not learn that 
anyone was doing anything in a surgical way for the cure of nerve 
syphilis. Tlie well-known fact that a surgical operation upon the cra- 
nium — opening the bony vault of the skull with the trephan — often 
determines the action of the iodide of potash in these cases of cerebral 
disease commonly attributed to venereal infections, seems to have passed 
unnoticed. 



A SURGICAL PILGRIMAGE TO ARKANSAS. 206 

Eureka Springs, in the northwest corner of Arkansas, has a wide 
reputation on account of the purity of its waters. They are quite free 
from solids, and are cold, carrying more oxygen than the waters of 
Hot Springs. The purity of its air, and the very rugged, broken char- 
acter of the country in which they are located, commands attention. 
There are more than forty springs inside the town, and one can get his 
fill of the solvent diluent at almost every corner. In the treatment of 
rheumatism and nephritis, these waters are quite unsurpassed. The 
man with the torpid, sluggish liver, renal insufficiency, and a feeble 
heart, will, if he drinks these waters and climbs these hills under the 
direction of a skilled physician, commonly find the obstruction to his 
circulation soon disappear, his respiration grows less frequent, his 
sleep become less fitful and restless, and his general condition vastly 
improved ; but even here I found, in conversation with physicians, that 
a high degree of skill is necessary to achieve results in the treatment of 
rheumatism, nephritis, eczema, or the distressing pruritus, often found as 
symptoms of impaired nutrition of the central nervous system. Nor is 
Eureka Springs a surgical town ; there is not a hospital or sanitarium 
in the town. All the surgery is the homemade sort, and is per- 
formed wherever the need of it is manifest. People with tumors do 
not come here, although I believe not a few cases might be found in 
which the solvent action of the water in cases of chronic empyema of 
the gall-bladder, and the agglutination of the ducts might be supple- 
mented by a surgical operation for drainage of the gall-bladder. Bath- 
houses are plentiful, fine hotels are numerous, good food is abundant, 
and pure air is universal at Eureka Springs. In a talk with Doctor 
Russell G. Floyd, who has a wide reputation in the treatment of 
nephritis, I was pleased to learn that he advised stripping the kidney 
in many of the cases of water-log nephritis, that he gave the patient 
plenty of the pure waters of the springs to drink, that he prescribed 
digitalis, and that he subjected them to vapor baths, massage, and cold 
douches with the most gratifying results. Doctor Floyd invariably 
treats the eczemas and pruritics with copious dilutions of the fluids of 
the body, by having the patient drink daily one or two gallons of the 
pure spring water, and bathe in warm spring water, whitened with 
bags containing four or five pounds of bran to each twenty gallons of 
water. Exercise on the hills, climbing the mountain paths, or follow- 
ing the bridk trails on horseback are valuable accessories of his treat- 
ment. The country here is free from mosquitoes, and no stagnant 
water is found anywhere. The whole region around about is underlaid 
with caverns, and into these the waters filter through the flinty soil, 
to appear finally in the beautiful strong flowing White river which 
rises in and drains this region of the Ozarks. 

I learned of a fever not altogether rare, which the doctors told me 
is neither typhoid nor malaria, but may be appendicial. It seizes the 
patient in the form of a high temperature, lasts from three to four 
weeks, and commonly ends in recovery if treated with hot sponge 



206 ORIGINAL ARTICLES. 

bathing. It lacks the stepladder rise of temperature in typhoid, as well 
as the intermission and the remission of the malarial fevers. Xor is it 
in the least influenced by quinine. It occurs at almost any season of 
the year and is found in any part of the Ozark mountains. The local 
doctors call it mountain fever, slow fever. It is never epidemic, nor 
is it moscjuito-born, for it prevails in localities where mosquitos are 
never seen. There is tenderness in the reg^ion of the appendix in most 
of the cases, quite suggestive of appendicitis. May it not be a type 
of ulceration of the appendix mucosa, allied to the ulceration of Pyer*s 
patches, a characteristic of typhoid? Near the I>asin Park Hotel is a 
large spring and a little park, where, during the Ix-ttcr ])art of the two 
himdred odd bright days of the year, may be seen numbers of people, 
who come here to drink the water, and increase their stock of health. 
The pallid face, the puffy eyelids, and the hurried respiration of the 
nephritic patient is frequently seen among them, and in almost every 
instance these people are improved, not a few being absolutely cured 
by the waters of the springs and surgical stripping of the kidney. 

Fort Smith. Arkansas, is a city of twenty odd thousand people on 
the border of Indian Territory. It is in Sebastian county on the 
Arkansas river at the head of steamboat navigation. The Sebastian 
County Medical Society has a membership of forty-two, but there are 
about one hundred seventy-five doctors in the city, and they are all 
either irregulars, eclectics, or homeopaths. The mass of practice is 
in the hands of the irregulars. The profession lives in reasonable 
harmony. There are several very good surgeons, who operate at the 
City Hospital and at the Saint Vincent, a Catholic hospital. There is, 
however, no great amount of surgery done. Some of the operators 
having met with disaster in their abdominal work have caused the 
people generally to be averse to surgical procedures. They prefer to 
trust to powdered roots, fluid extracts, and divers teas for the relief 
of their ills. Some of the doctors, however, have large practice, visit 
a great many patients, and put up or dispense bushels of medicine. 
Malarial fevers are not uncommon. Quinine and other alkaloids of 
Peruvian bark are in constant use. Calomel and epsom salt seem to 
be effective in most of the abdominal cases. The positive obstructions 
are either operated upon, with more or less reluctance, or go surely to 
the bad. I could not learn that there was much surgical enthusiasm 
in Fort Smith. It is a fine growing city, full of splendid homes, in 
the midst of a fertile country, maintains two ambulances owned by 
undertakers, who are a thrifty class. There is an. opportunity in Fort 
Smith for an apostle of surgery, but he must cure the people whom he 
operates upon. 

My medical jaunt to Arkansas would not be complete without some 
account of Little Rock, the capital of the state, wdiere are located the 
niedical department of the Arkansas Industrial University, Saint Vin- 
cent's Hospital, and the Logan H. Root Hospital. Mr. Root endowed 
the hospital with $too.ooo, but only $10,000 of that sum was found 



A SURGICAL PILGRIMAGE TO ARKANSAS. 207 

available by his executors for the uses of the institution. The clinics 
of the medical college are in part held there, and as good courses in 
clinical medicine and surgery are given in Little Rock as in any city 
of its size in the United States. The Medical College was founded 
about twenty years ago and it numbers among its alumni many of the 
ablest physicians of the state. Little Rock has about fifty thousand 
people and is growing. It has Saint Vincent's Hospital, a church 
institution; a Railroad Hospital under the care of Doctor Joseph 
P. Runyon, who is generally recognized as one of the leading surgeons 
of the city ; and a City Hospital, in charge of Doctor Watkins, the city 
physician. At the County Hospital and Poor House, a short distance 
from the city, senior medical students act as internes, and get a part of 
their course in clinical obstetrics. Little Rock has a School for the 
Blind — both white and colored, a School for the Deaf — both white and 
colored, the State Penitentiary, and the Asylum for the Insane, which 
contains more than one thousand patients. All of these institutions 
furnish more or less medical and surgical work, which is available for 
the instruction of industrious and enterprising medical men. In the 
Asylum for the Insane the custodial features of the work is paramount, 
but not a little attention, probably fully as much as in asylums generally, 
is given to the internal medication of the patients. Gastrointestinal 
work is done tentatively, but every patient is given a careful physical 
examination, which supplements the perfunctory examination carried 
out under the direction of the county judge. There is, however, no 
reason to contrast the medical and surgical care of the insane of Arkan- 
sas, outside of the Poor House in Garland county, with the care that 
is given those people in other states. At Fort Smith they have a fine 
Poor House under the care of able physicians, and the most conscien- 
tious and discriminating treatment is given to the patients. The same 
may be said of that institution at Little Rock and of the asylums gen- 
erally. The blot on the escutcheon of Arkansas in Garland county, 
near Little Rock, a prominent physician in Little Rock told me, is the 
fact that Hot Springs is the mecca for countless thousands of people, 
mostly poor, who suflfer from constitutional diseases and pour into Hot 
Springs in great numbers. If the municipality built a city hospital 
they would swamp it. If they kept a decent Poor House they would 
swamp it. ]\Iost of the inmates of the County Poor House were from 
other counties and states, who had come to Hot Springs with the hope 
that the hot waters would heal them, and had no means to get away. 
He further said that it was the policy of the municipality of Hot 
Springs to discourage the coming of poor people to that place, by with- 
holding all the usual eleemosynary institutions from their use. Even 
the jail, I found overcrowded and a relic of antiquity. It was built 
in the early days of the county and ought to discourage every evil- 
minded person w'ho looks at it, much less stays in it. 

The expectation of finding any considerable amount of up-to-date 
surgery and surgical institutions in Arkansas were not fruitless; and 



208 ORIGINAL ARTICLES. 

there is good reason to believe that the small band of vigorous, aggress- 
ive, well-equipped practitioners of the chirurgic art will meet with 
better reward in the near future. The wealth of Arkansas forests, her 
mines of coal and metal, her cattle, sheep and hogs, her grain and cotton 
cannot help but bring a population which will want more and better 
schools, ask more and better care of their minds and bodies, and con- 
sequently give employment liberal and ample to those who stand today 
. for the advancement of medicine along the most progressive lines. 



THE VALUE OF TIME AND NATURAL UTERINE EFFORTS 
IN PARTURITION.* 

By ALVAH N. COLLINS, M. D, Detroit. 

If the signs of the times indicate anything to the more mature 
medical student, they indicate a closer study of the natural processes 
in the care and cure of those seeking our advice and assistance. This 
is true as well of surgery as it is in so-called general medicine and 
obstetrics. In general medicine we cannot fail to note a falling off in 
complex drugging and active interference. Given a complex prescrip- 
tion containing a 4ialf dozen different ingredients, the ultimate action 
of which, given separately, we know little enough, when combined, we 
know less. We had a specific that was good for this symptom and 
that symptom, while at the same time it might be hammering the life 
out of some other vital part of our machinery, unnoticed, in our mad 
pursuit of the particular symptom. How the multitudinous remedies 
have dwindled in this renaissance of more accurate observation. Just 
now in all branches of medicine the pendulum of all active interference 
without a very plain indication is swinging back toward a reasonable 
letting alone of all the natural processes unless we have a plain indi- 
cation for interfering, either mechanically or medicinally, with an 
organization in which countless generations have developed recuper- 
ative and curative properties and which, in many cases, now interfered 
with were much better left alone. The man who always has his 
monkey-wrench in his automobile will do considarable walking. The 
doctor who cannot keep his fingers out of the delicate processes of the 
animal machinery will often do irreparable damage to the nicely 
adjusted and wonderfully complex machinery of the living organfsm. 
Nevertheless, there are times when the monkey-wrench will help the 
machine and there are unquestionably times when the careful physician 
will assist in benefiting the laboring organism. I simply plead for more 
care and judgment when to, and when not to, interfere. If a labor is 
going along reasonably well, if there are no apparent reasons why a 
natural labor may not be consummated, in the name of all that is 
sacred let it alone. 

•Read at the Ann Arbor meeting of the First Councilor District Mrdical Soci- 
ety, December 22, 1905. 



NATURAL EFFORTS IN PARTURITION. 209 

The subject of obstetrics is a broad one, and I will confine myself 
to one phase — the value of time and natural uterine efforts in parturi- 
tion — drawing my conclusion very largely from mistakes that I have 
made myself, and from mistakes that I have seen, and known of others 
making. In an experience extending over a period of twenty years 
it was my misfortune to have a very large obstetric practice. I cannot 
compete with some figures I have heard as to number of cases so will 
give no figures, but conclusions drawn not so much from books as 
from the bedside. We need to have a fairly definite knowledge of 
what is the average time necessary for normal labor. We must take into 
consideration that this is so modified by individual peculiarifies that 
one patient may need hours for certain changes that are necessary for 
safe delivery to take place while another will only need minutes. Each 
patient has a normal period of time distinctly her own. Yet from the 
study of a large number of cases we estimate a fairly definite period 
during which the process is completed. This period, as you have all 
observed, often varies greatly in the same patient, differing presenta- 
tions, differing size of child, differing physical conditions, et cetera, 
all modifying the time needed for the most conservative and safe com- 
pletion of this truly awful phenomenon, parturition. 

Hirst states that the average duration of all labors is from twelve 
to fifteen hours: in primaparae from twelve to twenty- four hours; in 
multipara from six to twelve hours. 

In Spiegelberg's five hundred and six cases, commonly quoted, the 
three stages for primiparae are, stage of dilatation, fifteen hours ; expul- 
sion, two hours; third stage, one-half hour. Multiparae — dilatation, 
eight hours ; expulsion, one hour ; and placental, one-half hour. A proper 
conception of -the long time necessary to bring about a condition of the 
parts for a safe delivery, a delivery as free from injury to the struc- 
ture of the parturient canal and with as little offense to those organs 
as is possible, is the sine qua non of obstetrical practice. 

My observation and experience at the bedside have shown me con- 
clusively that more damage is needlessly done from a failure to remem- 
ber that the normal period of the stage of dilatation in primiparae is 
fifteen hours and may be thirty-six hours or more and still be normal 
for that case, than from any other one cause. I am satisfied that 
many a woman in her first labor is unnecessarily injured and made a 
semiinvalid, forever after to be a supplicant at the shrine of the gyne- 
cologist, from this failure on the part of the attendant to properly 
realize the necessity and value of time for the physiological changes to 
be brought about for safe delivery. I am not discussing abnormal 
conditions. Abnormal conditions may imperatively demand violent 
treatment of these organs as a lesser of two evils. Whenever we for- 
get the value of time in parturition, and with our anesthesia and our 
forceps force these delicate structures to dilate and stretch to their 
utmost and beyond before they have been prepared for the ordeal by 



210 ORIGINAL ARTICLES 

hours of natural effort we are meddling with a process greatly better 
let alone. 

The process of dilatation of the cervix, the obliteration of the cer- 
vical canal, the relaxation of the lower uterine segment or the so- 
called ring of Bandl is a slow process. If given time the uterine con- 
tractions, pulling by the longitudinal fibers from above against a con- 
ical wedge within the uterus, gradually dilate the opening, making 
the heretofore contracted canal a cylindrical part of the uterine body, 
permitting the escape of its contents without great injury to its own 
structure or unnecessary pull upon the ligaments supporting the 
uterus. This dilatation can by no mechanical means known, be so 
safely accomplished as by the physiological process attending the 
phenomena. A certain degree of edematous infiltration of the lower 
segment results from the paroxysmal contraction and the relaxation, 
which requires time. This infiltration permits relaxation without 
laceration. 

In the second stage of labor, in preparing the pelvic floor and 
vaginal outlet and perineum for the great distention that is to come, 
this infiltration is undoubtedly of the greatest value in permitting a 
relaxation without rupture. This process of infiltration requires time. 
In the second stage, especially in primiparae, without very clear indica- 
tion of necessity for hasty delivery, we should permit all the protective 
processes of infiltration, paroxysmal distension and recession, and 
gradual dilatation ; ample time to prepare for the stretching that must 
otherwise result in laceration; which in the majority of cases physio- 
logic law exacts. How unwise and how unscientific then does it 
become to resort to forceps before we have the best possible obliter- 
ation of the cervical canal and lower uterine segment which terminates 
the first stage of labor. 

To apply the forceps high up before the head has entered the brim 
or descended into the excavation, even with a well dilated or dilatable 
lower segment, is a dangerous procedure, I quote from the "Ameri- 
can Text-Book of Obstetrics": "It should be resorted to only in 
exceptional cases. The higher the head the more dangerous the pro- 
cedure." How much more dangerous to apply high forceps before we 
have a proper dilatation and exert the strength often applied to the pull 
upon a lower undilated uterine segment. What are we pulling upon ? 
We are dragging with all the force exerted, upon the uterine ligaments, 
the round ligaments, lower part of the broad ligaments and the utero- 
sacral bands. If the bony structure of the pelvis resists us we then 
endanger the anterior supports of the bladder, urethra, and vagina. 
If our eflforts are successful in dislodging the head from the rapidly 
dilated lower segments, what then occurs if we continue with our 
delivery ? ' We bring the head down upon the pelvic floor and peri- 
neum to the second stage of labor which requires normally two hours 
and may normally require from two to six hours. Do we sit there 



NATURAL EFFORTS IN PARTURITION. ^ 211 

from two to six hours or permit a proper time for the proper relaxa- 
tion of this pelvic floor? We should if we are to properly protect our 
patient. As a rule, when the forceps are on, the process is continual 
and the delivery completed within an hour at the outside. The result 
is unnecessary injury. We have not taken into consideration the 
value of time in this process. This picture is not overdrawn. A short 
time ago I was called to repair a primiparae where the whole process 
of the three stages had been accomplished with the forceps in about 
four hours. The result was two tired physicians and a genital tract 
that looked as though a stick of dynamite had been inserted therein 
and exploded. No sugeon can by any sort of repair ever overcome the 
damage done. The only recourse is to make the best, by careful effort, 
of what was rendered irreparable. It is because I have witnessed this 
sort of work so long that I wish to call attention to the trite subject — 
the value of time and natural uterine efforts in parturition. Again, in 
induced premature labor, I have seen the process so unduly hurried 
that a small child rapidly delivered caused such shock that the mother 
never recovered. Do not understand me to be criticizing necessary haste 
when haste is plainly the lesser of two evils ; but I wish to emphasize 
the dangers of too rapid delivery. I wish to state my conviction that 
in many cases of delivery today the forceps are used altogether too 
early and too often. We should not permit a woman to die of 
exhaustion, but the proportion of women dying of exhaustion and 
delayed labor are few compared with those invalided for life and dying 
from precipitate artificial delivery. 

Is there need to again direct attention to the evil results of hasty 
and forced delivery in the normal but slow parturient wcMnan? My 
experience answers this question in the aflirmative most emphatically. 
Once a pelvic floor is severely torn I very much doubt if any care, 
no matter how skillful the surgeon, can restore it to its original tone 
and function. We may carefully adjust the torn muscle and tissue 
in sight or in reach but we cannot see or reach the upper margin of 
the support. Recognizing this impossibility^ of complete restoration 
it becomes imperative that we use every means at command to prevent 
a condition being brought about which is incapable of repair. In my 
judgment the most efficient protection against calamities, farreaching 
in their immediate as well as remote effects, is in allowing plenty of 
time for the natural protective processes to physiologically prepare this 
tissue for its great distention. If given plenty of time a very difficult 
delivery, if forced, becomes relatively jeasy and free from danger. In 
many cases of prolapsus in later life the so-called rectocele and cysto- 
cele are due to too rapid delivery in the second stage of labor. No 
matter how carefully we may repair a perineum or how perfect our 
union, a vagina once torn from its pelvic attachments is very difficult 
if not impossible to repair. This detachment may be and usually is 



212 ORIGINAL ARTICLES. 

subcutaneous and undetected till the woman has been on her feet 
several weeks. 

There can be no reasonable doubt but that the early use of the for- 
ceps and the semivoluntary excessive bearing down of the patient, or 
in other words, too rapid movement in the second stage of labor, is the 
prime cause of this tearing away of the pelvic attachments of the 
vagina, the results of which are rectocele, cystocele, and later in life 
uterine prolapse. If this be true, in most cases we do our most effi- 
cient service by retarding rather than hastening the second stage of 
labor. With no contraindication I believe this procedure should nearly 
always be done by employing anesthesia and exerting manual press- 
ure upon the distended perineum. This can usually be accomplished 
by giving the parts ample time to relax to their utmost. You are all 
familiar with the complete lacerations often found in cases of precipi- 
tate labor when there has been no opportunity to protect these tissues 
by compelling a slower process. They but teach us what not to do 
with our forceps and how to protect these structures when opportunity 
is given. 

In the delivery of the oncoming shoulder, time again should be 
given. No doubt deep pelvic floor injury is often increased if not 
caused by a too rapid shoulder delivery. Time is here needed for 
rotation and adjustment of the bisacromial diameters to the antero- 
posterior diameter of the outlet. With the anterior shoulder behind 
the pubic bone, the cervicoacromial diameter permits the posterior 
shoulder to emerge first with less strain upon the pelvic floor. When- 
ever possible, with no contraindications aside from gently elevating 
the head, the posterior shoulder should be allowed to pass over 
the perineum with no effort at manual extraction whatever. This 
method of shoulder delivery is the natural one and simply requires let- 
ting alone largely till the physiologic forces complete their work. If 
any traction should be required in the delivery of a large child the pos- 
terior foreams should be gently flexed out over the perineum and a 
gentle traction upon the posterior shoulder made, allowing the yielding 
body to permit the delivery of the anterior shoulder under the pubic 
arch. Again, in the third stage or placental delivery the element of 
time is too often overlooked, and pushing from above and lugging at 
the cord below is resorted to instead of gently kneading the uterus and 
permitting a natural and complete delivery. You are all familiar with 
the saying that adherent placentae are found mostly in the first few 
cases attended. It is surprising how seldom they are found later in 
our professional careers. It requires from five to ten minutes for the 
relaxed and relatively empty uterus to regain sufficient contractability 
to commence efforts of placental expulsion. Its first efforts are usu- 
ally futile. More time and more stripping oflF by the retained blood 
are required. The only point we need to know is, has the uterus its 
tone? This, by manual touch through the abdominal wall, is readily 



NATURAL EFFORTS IN PARTURITION. 213 

determined. If permitted, within fifteen minutes or a half hour the 
process will be completed in a way more satisfactory and safe than man 
has devised. Again, the value of time versus meddling ! 

CONCLUSION. 

It requires time to bring about a proper condition of the cervix and 
lower segment of the uterus for the safe delivery of the presenting 
part. This is a variable time, and when there are no urgent contra- 
indications this time should be given — be it three hours or three days. 
My experience and observation force me to conclude that this is very 
often forgotten at the beside, with lamentabte consequences to our 
patients. The forceps are applied altogether too frequently and alto- 
gether too early in a great number of cases. When employed they 
are not used with sufficient deliberation, and results are brought 
about in minutes which, in order to properly protect the tissues, should 
take much longer time. The strain upon the tissues is too continuous 
to properly protect the child or the maternal tissues. The strain should 
be interrupted instead of continuous. The interval of strain should 
not exceed one-half minute without a relaxation. More time than is 
usually given is imperatively required if we are to relax instead of 
tear the tissues. We should not forget that we are pulling upon deli- 
cate structures which must oppose our strength with theirs, pound for 
pound. We should not forget that before time for relaxation has been 
given a force of fifty pounds will do more damage and accomplish less 
than a ten-pound pull with proper relaxation. We need to fix in our 
mind the time for the various stages of normal labor and conform as 
nearly as conditions will permit to these periods, not forgetting that 
more time in individual cases may be given when there are no plain 
contraindications. Watch the progress of natural labor with more 
of a readiness to assist natural processes than with an idea of taking 
the job entirely into our own hands. I quote the indications for the 
use of forceps from the "American Text-Book of Obstetrics.'* 

(i) Indicated in lingering labor when the natural efforts are 
unable to effect delivery. 

(2) When speedy delivery is imperative in the interest of the 
mother; as in hemorrhage, exhaustion, convulsion, advanced cardiac 
or pulmonary diseases, et cetera. 

(3) When speedy delivery is indicated in the interests of the child, 
as in impending death of the mother or threatened asphyxia of the 
child. 

And again, a quotation from Doctor John W. Clark in his "Resume 
of Prolapsus,'' published in the June (1905) number of "Progressive 
Medicine," expresses the facts of this subject : 

( I ) Never encourage a patient in labor to bear down until nature 
excites this inclination. 



214 ORIGINAL ARTICLES. 

(2) The use by the patient of tractors to increase the voluntary 
expulsion effort is questionable. 

(3) Never apply forceps without a complete dilatation of the cer- 
vix. When a more precipitate delivery is necessary it is best to incise 
the cervix. 

Never use forceps without a positive indication. Secure the gradual 
passage of the head through the vagina and over the perineum. 
The prevalent use of artificial force, the habitual use of the forceps 
without any prime indication for their use, the rapidity with which 
labor is consummated by these artificial means with the train of evils 
that follow this departure from natural physiological law is what I 
would emphasize. 

Because a patient or her friends insist that something be done is no 
valid indication for harmful practice. It is our duty to protect our 
patient's health and happiness. Reputation, pleasing friends, making 
a brilliant display of our activity, the saving of valuable time for rest 
or profit, are none of them valid excuses for unnecessarily hastening 
this process to the ultimate detriment of those who rely upon our skill, 
our knowledge, and our candor in this hour of woman's greatest pain 
and peril. 



TRANSACTIONS. 



CLINICAL SOCIETY OF THE NEW YORK POLYCLINIC. 



STATED MEETING, APRIL 2, 1906. 

The President, JOHN J. MacPHEE, M. D., in the Chair. 
Reported by FREDERICK C. KELLER. M. D., Secretary. 

REPORTS OF CASES. 

TUBERCULOSIS OF THE CARPUS. 

Doctor Victor C. Pedersen : I wish to present this patient, a 
young woman who has suffered from tuberculosis of the wrist for 
many years. Several years ago a palmar operation was performed in 
a small town up the state, but there are no evidences that tuberculosis 
ever existed in the hand. Two years ago the wrist was operated on, 
a median incision being made, and a year ago two lateral incisions were 
made. The wrist is now free from pain, and except for the ankylosis 
of the joints which followed the first operation, there is no difficulty 
in using the wrist. In dealing with tuberculosis of the wrist, an oper- 
ator often forgets the diverticulum of synovial tissue which passes 
upward between the radius and the ulna. At the last operation per- 
formed upon this patient, it was at this point that the first foci of 
tuberculosis was found. The largest synovial pouch passes forward 
between the surfaces of the metacarpal bones, and here was found the 



CLINICAL SOCIETY. 215 

second foci. Both foci were removed and the patient recovered. As 
a matter of precaution, she is wearing a metal splint while performing 
her household duties. The ankylosis of the fingers is the result of the 
operation performed four years ago, and nothing seems ot correct it. 

GUMMA OF THE FRONTAL BONE, 

Doctor Pedersen : I also wish to present this patient. I first saw 
this man last summer, eight weeks after he had received a violent blow 
on the head. At that time there was a tumor, which was supposed to 
be an adenoma, partly chancroidal, partly syphilitic. It traveled down 
under the skin, down into the fatty tissue, eating out large masses of 
the tissue, and finally was stopped by bromidia water. Soon after the 
lesion on the head broke and took on the characteristics of a specific 
lesion and was dressed surgically. There seemed to be a fissure in 
the skull, which had been previously treated, and exfoliation of the 
bone took place. There was no temperature except that which would 
naturally accompany anemia. At one time the lesion was thought to 
be tubercular, but recovery under specific treatment seemed to confirm 
the diagnosis of gumma with profound anemia. 

DESTRUCTION OF TISSUE AND NAILS OF FOOT, 

Doctor Pedersen : I will also present another patient, who came 
to the House of Relief two weeks ago, having been discharged from 
one of the city hospitals. The nails of the left foot and the tissue sur- 
rounding them showed evidence of great destruction, and there was a 
great deal of pus. The interesting question was whether to apply blue 
ointment or a wet dressing. The patient's conditions of life made it 
impossible for him to obtain any benefit from a wet dressing, so blue 
ointment was used, with beneficial results. The foot presented an 
appearance very similar to nephritis, but the other foot is not at all 
swollen. 

VARICOSE VEINS, 

Doctor Alexander Lyle : I desire to present this patient, a man, 
forty-eight years of age, who suffered from scarlet fever and whooping- 
cough as a child, and from typhoid fever when twenty-eight years of 
age. He is a heavy smoker and beer drinker. His present trouble 
dates back twenty years to swelling of the ankles. The veins of the 
right leg ulcerated several years ago, and a diagnosis of varicose veins 
was made. The ulcers are very large in both legs, but cause the 
patient no discomfort. I am of the opinion that at the time of the 
typhoid a thrombus had formed in the injured vena cava, and the 
superficial veins had taken up the circulation. No abdominal tumor 
can be located, and the veins all originate above the brim of the pelvis. 

NEPHRECTOMY. 

Doctor F. C. Yeoman : I wish to report the case of a man, aged 
fifty-six, who has been a heavy consumer of alcohol. About seven 
months previous to operation he was seized with a severe pain in the 



216 ORIGINAL ARTICLES. 

right groin, shooting downward to the groin and corona glandis, and 
the next day passed blood clots in his urine, but never passed any 
gravel to his knowledge. During the next three months he had 
attacks resembling renal colic at intervals of from two to five weeks, 
passing clots but no stones. During the past two months he had suf- 
fered severe intermittent pain during the night, beginning in the hypo- 
chondrium and extending over to the midline; also intermittent pain 
referred to the knees, more marked on the right side. The urine of 
late has been free from albumin and never showed any crystals. The 
patient's strength gradually diminished and he lost about forty-five 
pounds in weight. No tumor could be felt seven months ago, but dur- 
ing the past three months a mass gradually increasing in size has occu- 
pied the right hypochondrium. Patient would not permit cystoscopy. 
He was admitted to the Polyclinic Hospital February 15, demanding 
operation for the relief of intolerable pain, although he had refused all 
previous suggestic^s of surgical interference. His lungs, on physical 
examination, were found to be normal ; heart-sounds soft, no murmur ; 
radials moderately thickened. The abdomen was relaxed and the upper 
limit of liver dullness diminished one intercostal space. The right 
hypochondrium showed a tumor ovoid below, descending on deep 
inspiration to a position opposite the umbilicus. On pressure it took 
the position occupied by the normal kidney. Blood examination 
showed a white count of eight thousand, hemoglobin, one hundred per 
cent. 

A right nephrectomy was done on February 20. The operation 
was difficult, as the kidney was about three times the normal size, cov- 
ered with a network of veins, and adherent on all sides. The wound 
was closed, except for cigarette drains at angles. The time of opera- 
tion was one and one-half hours, and the patient rallied fairly well; 
but the following two days there was almost total suppression of 
urine, only two ounces being secreted. Thereafter his condition 
improved, and he secreted about the same amount and character of 
urine as before the operation; but at the end of a week he began to 
fail, and died on the eighth day. Autopsy was refused, and thus the 
opportunity of discovering if metastases had occurred was lost. 

A cursory review of the reported cases of hypernephroma warrants 
the following tentative conclusions: Metastases is the rule, especially 
to the liver, lungs and bones. These tumors have a tendency to spread 
and involve veins, but no lymphatics. The renal brim is usually 
involved, and sometimes the cava, but does not obstruct sufficiently to 
cause edema of the extremities. In a few cases the growth long 
remains local and can be successfully removed. Clinically, the symp- 
tom that may be of diagnostic value is bleeding and its results. Tumor 
and pain are present as in several other renal affections. Periodic 
attacks of hemorrhage, with frequency of micturition, often with pas- 
sage of clots, seem characteristic. These clots sometimes block the 
ureter, cause diminished urine, and the pain is referred to the corona 



CLINICAL SOCIETY. 217 

glandis. Between the attacks of bleeding there is fairly constant pain 
in the back. A fresh hemorrhage relieves the pain, thus contrasting 
with pain and bleeding connected with the passage of stone. 

PATHOLOGIC SPECIMENS. 

Professor J. H. Larkin, of Columbia University : I shall present 
some pathologic specimens of great interest and give the history of 
each, insofar as I have been able to obtain it. The first are of diseased 
appendages, a field of surgical research which is becoming more and 
more important. Until a few years ago it was supposed that lesions of 
the pancreas, as found at postmortem examinations, were fairly well 
understood, although little was known of the etiologic significance; 
but now pathologists are able to show the causative factor. Its close 
relationship to cholelithiasis and other diseases of the intestinal tract 
has been understood for some time. The clinical histories in these 
cases are very similar. There is usually a severe onset of gastric pain 
that at times is almost diagnostic to the surgeon of appendicitis or 
intestinal obstruction, apd many patients have been operated on for one 
or the other of these conditions. In the majority of cases, stone in 
the ampulla duct has been a very common factor. The specimen which 
I present is mounted so as to preserve its normal color. On the right 
side is a portion of the duct and on the left a portion of the pancreas. 
It is presumed that one or more stones had been passed in this case, 
because of the immense dilatation of the common duct. The lesion is 
easily explained, and experiments have reproduced exactly the same 
condition. The stone passes down into the common duct and is 
impacted at Bardes' ampulla, and this leaves a continuous passage from 
the common duct to the ampulla, and the bile, instead of going down, 
is sidetracked and goes directly into the pancreas, and this produces 
hemorrhagic pancreatitis. This can be reproduced by putting bile into 
the pancreatic duct, or a solution of hydrochloric acid will produce the 
same result. 

The next specimen shows the connection of the pancreas with the 
duct, and also shows the gall-bladder with an immense amount of 
stone. Of the several interesting brain specimens which I present, no 
clinical histories could be .obtained. One specimen is from a patient 
who had been under observation for some time, and whose condition 
had been diagnosed as cerebral abscess. The specimen shows one side 
of the brain, with the cerebellum and one cubic centimeter of hemor- 
rhagic blood which was removed at time of operation. 

EXHIBITION OF INSTRUMENTS, 

Doctor J. E. Fuld : I wish to present this intestinal depressor. I 
devised it for the purpose of depressing the intestines to prevent them 
from extruding into the abdominal wound and interfering with the 
operator. Gauze pads are usually inserted to overcome this difficulty. 
The instrument has proved of value in pushing aside not only the 
intestines, but the other abdominal contents as well, thus affording the 



218 ORIGINAL ABSTRACTS. 

Operator a full view of the area to be inspected. The instrument is of 
polished steel, and shaped something like the ordinary glass tcfigue 
depressor, being eight inches long, one and one-half inches wide at 
one end and three-quarters of an inch wide at the other. 



ORIGINAL ABSTRACTS. 



MEDICINE. 

By GEORGK dock, A.M., M. D., D.Sc. Ann Arbor, Michigan. 

PKOPB8SOK OF MBOtCINB IN TMB UmVUISmr OW MICHIGAN. 

AND 

DAVID MURRAY COWIE, M. D., Ann Arbor, Michigan. 



COURVOISIER'S LAW: ITS VALUE IN THE DIFFEREN- 
TIAL DIAGNOSIS OF OBSTRUCTIVE JAUNDICE. 

MoYNiHAN, in the May issue of the Edinburgh Medical Journal, 
contributes an article "On the Violation of Courvoisier's Law," from 
which I abstract and rearrange what seem to be the most important 
points. 

The Law. — **In cases of chronic jaundice due to obstruction of the 
common bile duct, a contraction of the gall-bladder signifies that the 
obstruction is due to stone; a dilatation of the gall-bladder, that the 
obstruction is due to causes other than stone." 

Courvoisier's explanation of the contraction or sclerosis of the gall- 
bladder is that stones had been present in the gall-bladder for long 
periods; that their presence had caused recurring attacks of cholecys- 
titis, and that, as a result, the gall-bladder walls had become thickened 
and fibrous. The gall-bladder so affected, became by degrees more and 
more shrunken, and at last was represented by a shrivelled mass of 
fibrous tissue, its cavity was greatly reduced in size, or almost oblit- 
erated, and the shrunken dense adhesions hid it from sight. Oft 
repeated attacks of cholecystitis and peritonitis resulted in cicatricial 
compression and cramping of the gall-bladder. 

Confirmation of the law has been made by Ferrier of France, Mayo 
Robson of England, and A. Cabot in this country. Moynihan cites a 
few cases which are directly in violation of Courvoisier's law, but calls 
attention to the fact that Courvoisier himself recognized that the law 
may sometimes be flagrantly infringed, and agrees with those just 
mentioned that in the great majority of cases that came under his own 
observation, the law has proved to be correct, but like all other laws is 
capable of infraction. 

Moynihan sums up his short but very comprehensive paper by 



J 



VARICOSE VEINS. 219 

giving the following chief circumstances in which the law may be 
violated : 

(i) Where there is a stone or a stricture in the cystic duct causing 
hydrops or empyema, together with the acute impaction of a stone in 
the common duct. 

(2) Where there is a stone in the cystic duct pressing upon the 
common duct. 

(3) Where there is distension of the gall-bladder by an acute 
inflammatory process, with obstruction of the common duct by stone. 

(4) Where there is chronic induration of the head of the pan- 
creas, with a stone in the common duct. 

(5) Where there is malignant disease of the common duct at any^ 
part of its course, or cancer of the head of the pancreas, and a chronic 
sclerosing cholecystitis. 

The validity of the law is established in at least ninety per cent of 
the cases in practice. 

The value of the paper is in its suggestion for more careful differ- 
entiation of cases presenting the symptom of obstructive jaundice. 

D. M. c. 



SURGERY. 

By frank BANGHART WALKER, Ph. B., M. D., Detroit. Michigan. 
rmovBStoM or sukgbkt and opskativb sukobrt in thb dbtkoit porroKADUATB SCHOOL OF mbdicinb; 

ADJUNCT PKOFBSSOR OF OPBSATIVB SURGBRY IN THB DBTIIOIT COLLBGB OP MBOICINB. 

AND 

CYRENUS GARRITT DARLING, M. D., Ann Arbor, Michigan. 

CLINICAL PROFBSaOB OF SUB6BKT IN THB VNIVICUrrT OF MICHIGAN. 



TREATMENT OF VARICOSE VEINS. 

Charles H. Mayo, M. D., of Rochester, Minnesota, in Surgery, 
Gynecology and Obstetrics, April, 1906. Of the many operations 
advised for the relief of varicose veins no one is suited to all cases. 
Not only the superficial veins produce the symptoms but the deeper 
veins are probably enlarged. The long or internal and the short or 
external sapheni veins are the ones usually affected. These connect 
at the knee and the internal also connects with the deeper veins at this 
point. The internal extends from the saphenous opening to the ankle 
and joins the external saphenous through the dorsal vein of the foot. 
These veins contain a number of valves which aid in separating the 
blood column. The internal vein is accompanied by the internal 
saphenous nerve, and the external vein by the external saphenous nerve. 

The cause of varicose veins is difficult, in many cases, to under- 
stand. In some it may mean congenital defect in the vein walls, valves, 
or enervation. In some cases pregnancy is given as a cause and in 
others pressure of tumors or injury. Vocation oftentimes increases 
the condition and symptoms. The condition may begin as early as 
twenty years, but many years may elapse before disabling symptoms 



220 ORIGINAL ABSTRACTS. 

may appear. The symptoms, which are well known, consist of ^fullness 
or weight of the leg with edema and pain. This may lead to pruritus 
or eczema. Local hemorrhages are frequent and may lead to pigmen- 
tation and discoloration of the skin ; or, the tissues may break down, 
forming ulcers. 

The so-called Trendelenburg phenomenon is tested by lifting the 
leg while the patient is lying down, and when the veins are empty the 
long saphenous is compressed above. The patient now stands erect 
and the pressure is removed and if the veins fill from below the valves 
are intact; and if the waves of blood descend the valves are useless. 
A few cases may be relieved by a change of vocation or climate, others 
are required to wear elastic supports such as bandages or stockings. 
Operative measures for relief are as old as the history of surgery and 
include ignipuncture with Paquelin or electro-cautery, cutaneous and 
subcutaneous ligation which are now seldom used, injections of irri- 
tants in and about the veins, multiple ligation and excisions, multiple 
incisions with torsion, removal, or Trendelenburg's operation which 
consists in ligating and removing a short section from the upper por- 
tion of the long saphenous. The more recent methods are subcu- 
taneous removal in suitable cases and nerve stretching. To test the 
advisability of operation an elastic bandage is applied from the foot to 
above the knee. If this bandage can be worn with comfort the oper- 
ation should give relief as the pressure shows that superficial vessels 
are not necessary to circulation of the limb. 

The writer reports one hundred eighty-five cases operated upon, 
many times operation including both limbs. A number of changes or 
modifications have been made in the operation. To aid in the work a 
ring vein enucleator and a pair of forceps, the end of which forms a 
ring when closed, have been invented. This operation is described as 
follows : 

"The vein is sought for and severed in the upper third of the thigh. 
The proximal end is ligated. The lower end is passed through the 
ring of the enucleator or placed in the ring of the forceps, and clamps 
are placed on the end of the vein. By a gentle pushing force, the vein 
being held to make tension and the tissues steadied on either side by 
an assistant, the ring or forceps is pushed down the vessel for six or 
eight inches, tearing off the lateral branches, when the point of the 
instrument is forced against the skin from beneath and a small incision 
is made to the ring or forceps, which is pushed through the opening, 
holding the vein like a thread in a needle's eye. The vein-loop is 
drawn out of the opening and also from the instrument, which is 
removed, rethreaded on the vein, and is pushed down to a lower point, 
where a small incision is again made and the process of removal 
repeated. The small lateral branches are torn off, and, as a rule, 
have enough muscle structure to close themselves. Should the main 
venous trunk break, a new incision is made below the knee, the vein 



INFLUENCE OF FEEDING ON INFANT MORTALITY. 221 

exposed and divided, and the enucleation made in both directions from 
this point. Below the knee the branches are larger and the vein is 
more adherent, being more superficial, so that a shorter distance must 
be travelled. If it is found that calcareous deposits, sacculations, or 
extreme weakness of the walls render the case unsuited to the enucle- 
ation method, and this occurs in about ten per cent of the cases, the 
principle of operation should then be changed to an open method, 
undermining only the section by the knee. Hemorrhage is avoided, 
first by position. An ordinary gynecologic standard is placed in 
position, and the leg raised in straight or extended position and sup- 
ported by the ankle. The position renders the limb partially bloodless, 
and also secures elevation and accessibility of the field of operation. 
Should any branches cause more than ordinary hemorrhage, it can be 
checked by a pressure-pad held against the skin over the region from 
which the veins were removed, or by small packs, which are left for a 
few minutes in the incision from which it arises." 

When ulcers are present the ulcerated area is excised and skin- 
grafted. Eczematous areas are painted with compound tincture of 
benzoin or an acetic solution of gutta-percha which acts as an antisep- 
tic varnish. The leg is kept elevated for twelve days. Recurrence 
may come from widening of collateral veins, formation of new veins or, 
as is claimed, from the regeneration of the saphenous itself. 

The dangers from operation are pulmonary' embolism. Sepsis is 
rare, although a serious possibility, and difficult to guard against in 
some cases with ulcer and eczema. 



PEDIATRICS. 

By ARTHUR DAVID HOLMES, M. D.,C. M., Detroit, Michigan. 



INFLUENCE OF FEEDING ON INFANT MORTALITY. 

HowARTH (Lancet, July 22, 1905), having investigated this ques- 
tion in eight thousand three hundred forty-two children, says the death- 
rate among the hand-fed was nearly three times as high as that among 
the breast-fed and twice that of children reared on mixed feeding. 
Among children who were first breast-fed and subsequently hand-fed 
the death-rate was not so high as among the purely hand^fed, showing 
the advantage accruing to children who have natural food supple- 
mented by artificial, rather than an entire supply of the latter. Children 
fed on condensed milk show a very high mortality, and children reared 
on bread, rusks, arrowroot and other farinaceous foods come next. 
His deductions are as follows : The use of sweetened condensed milk, 
either whole or skimmed, should invariably be discouraged, and whole 
unsweetened condensed milk only should be permitted where one is 
satisfied that the milk is being used with a proper degree of dilution and 
.with the necessary additions, as in the case of modified cow's milk; 



222 ORIGINAL ABSTRACTS. 

also that since the death-rate among children reared on patent foods 
is, on the average, higher than among those fed on diluted cow's milk, 
every attempt should be made to encourage parents to use the latter 
food and to educate them to an appreciation of the necessity for the 
additions to, and the dilution of, cow's milk to render it suitable for 
infant's food. The addition of patent foods to the dietary of very young 
infants is unnecessary, sometimes dangerous and always expensive. 
Furthermore, it must not be forgotten that the risks to which hand-fed 
children are exposed are considerably minimized by mixed feeding and 
that therefore every mother who is unable fully to satisfy her infant 
should be encouraged to continue to feed her child and to supplement 
any deficiency by means of artificial foods, and that only in ease of 
absolute necessity should resort be had to artificial feeding alone. 



OPHTHALMOLOGY. 

By WALTER ROBERT PARKER. B. S.. M. D. 

rKOFBSSOIt OF OPUTUALHOLOGT IN THB UMIVBKSITT OF MICHIGAN. 



HOW A LIGHT SHOULD BE PLACED FOR READING. 

Cravath and Lansing, in The Electrical World, of January 6. 
The general lighting of small living rooms and parlors, together with 
the location of lights for reading in such rooms, is discussed, with 
criticism of special cases. The writers note at the outset that the 
general lighting of a small living room and the provision for reading 
lights are so closely connected that they must necessarily be considered 
together. They write : 

"The reading light is the one that is likely to be used constantly 
and has so much to do with the comfort and eyesight of members of the 
family that it needs earnest consideration. There are three common 
ways of obtaining a reading light. One way is to illuminate the 
whole room so brightly that reading is easy in any part of it. This is 
usually undesirable for two reasons: One is that the eye is likely to 
tire more quickly in a room so brightly illuminated in all corners than 
it would be if it had an opportunity to rest by looking from the lighter 
to the darker parts of the room occasionally. The cost of lighting a 
room so brilliantly as this makes it out of the question in the majority 
of .rooms. We will, therefore, leave out of consideration this method 
of securing a reading light and consider the second and third methods. 
The second method is to use a lamp placed near the reader and fitted 
with a globe or reflector which will concentrate nearly all the light on 
the book or paper. If we do this, the reading lamp is likely to be of 
little value in the general lighting of the room and we will have to 
add other lights besides the reading lamp if the greater part of the 
room is not to be in comparative darkness. The third method, which 
is the one usually to be preferred where the greatest economy is an 



LOCATION OF LIGHT FOR READING. 223 

object, is to use the same light both for reading and for the general 
lighting of the room by equipping the reading light with a globe or 
reflector which will concentrate a considerable portion of its light 
within the area in which it is desired to read and at the same time 
allow enough light to radiate in all directions to give fairly good illu- 
mination over the rest of the room." 

The popular impression that a portable table lamp is better adapted 
to reading than a lamp on a chandelier or bracket is regarded by the 
authors as a misconception, such table lamps being merely an inheri- 
tance from the days of the candle and oil lamps. They say : 

"With electric light, usually much more satisfactory results can be 
obtained with a properly equipped reading light on or suspended from 
the chandelier or on a bracket on one of the side walls. The reason 
for this is that it is impossible with a table lamp to secure a reflector 
which will throw as large a proportion of the light where it is needed 
for reading purposes as can be obtained from the proper reflectors on 
chandeliers and brackets. Most of the electric portable stand lamps 
throw the greater part of the light down on the table around the base 
of the lamp, so that the readers sitting around the table get only a small 
percentage of the light. If the portable stand lamp is used on a library 
table where the readers place their bodes on the table each side of the 
lamp its use is permissible, but such is not the usual condition. 

"There is also considerable misconception as to the comparative 
distance from the reader of a lamp located six feet above the floor on a 
chandelier as against a lamp located on a table. The average person 
who has never measured these distances is under the impression that 
the lamp on the reading table is much nearer. As a matter of fact, the 
distances are nearly the same. There is really for the majority of 
cases only about one thing to be said in favor of an electric table lamp 
for reading as against a properly equipped lamp on a chandelier or 
bracket. This is that with the table lamp it is not as likely that a 
reader will get the regular reflection commonly known as "glare" from 
a page of white paper because the light comes so much from one side. 
In reading underneath a lamp on a chandelier or bracket the reader 
must turn the page at such an angle that he does not receive this glare 
from the paper. This is easily done, but many people undoubtedly 
suffer from this without knowing what is the trouble or taking pains 
to find out. Since this glare of regular reflection is likely to be more 
pronounced with electric light than with kerosene lamps, it is probable 
that this is responsible for the preference that some people have for 
oil reading lamps, even though electric light is available in the rest of 
the house." 

In advocating the use of reading lamps placed on chandeliers and 
brackets rather than table lamps, the authors disclaim a desire to advise 
trying to read with chandeliers arranged for the general illumination 
of the room. Chandeliers to be used for reading lights should be 
especially equipped for the purpose. 



224 ORIGINAL ABSTRACTS. 

OTOLOGY. 



By R. bishop CANFIELD, A. B.. M. D., Ann Arbor. Michigan. 

PKOrSSSOB OF OTOLARYNGOLOGY IN THB UNIVUSITY OF MICHIGAN. 

AND 

WILLIAM ROBINSON LYMAN, A. B., M. D., Ann Arbor, Michigan. 

OBMONSTKATOS OF OTOLAKYNGOLOGY IN THB UNIYBRSITY OF MICHIGAN. 



A CASE OF ACUTE MIDDLE EAR SUPPURATION, COM- 
PLICATED BY LABYRINTHINE FISTULA AND 
PARALYSIS OF THE ABDUCENS NERVE. 

HiLL Hastings, M. D., in Archives of Otology, Volume XXXV, 
Number I. Twenty cases of paralysis of the abducens nerve have 
been reported. This case presented at re-operation a fistula through 
the inner tympanic wall as the probable avenue of extension of the 
infection. Gradenigo concluded that this syndrome of clinical symp- 
toms is the result of a circumscribed simple serous leptomeningitis 
localized about the tip of the pyramid and caused by the diffusion 
of the infection in the tympanum generally through the tegmen 
tympani. 

The patient was a male, twenty-two years old, who had an acute 
ear trouble following a head cold. The ear showed some purulent 
discharge, sagging of the posterior superior canal and an inflamed 
bulging membrane with a small perforation. Moderate mastoid ten- 
derness, chiefly over antrum and tip. Some tinnitis but no dizziness or 
other symptoms. A free incision was made in the membrane. Three 
days later the mastoid operation was performed with no findings of 
especial interest. After operation discharge and pain continued and 
gradually increased though the mastoid wound was clean. There was 
some dizziness and marked tinnitus. The membrane remained red and 
bulging and was incised two or three times to offer better drainage. 
On the twelfth day the patient complained of increased dizziness and 
double vision. Examination showed marked diplopia due to paralysis 
of the abducens. No other motor or sensory disturbance. As this 
case was an acute one and the hearing had been normal a radical opera- 
tion was deferred. As the paralysis continued and the pain and dizzi- 
ness increased a radical mastoid operation was done on the eleventh day 
after the appearance of the paralysis. 

The tympanic cavity was found full of granulations and pus; 
malleus and incus were normal. When the cavity was cleansed pus 
could be seen coming from the inner tympanic wall in the recess of 
the oval window apparently through that opening. The stapes was 
not found. The fistula was found to lead inward for half a centi- 
meter before bony resistance was noticed. The opening was enlarged 
and the fistula swabbed out with bichloride solution. No other 
necrosis of the tympanum was found. A Ballance flap was made and 
sutured above; the posterior wound was left open. Facial twitching 



TREATMENT ON MYCOSIS. 225 

occurred during the operation due to injury to the horizontal portion 
of the facial canal which formed the upper rim of the fistula. 

After the operation the pain subsided. The paralysis gradually 
passed off and the diplopia entirely disappeared in four weeks. The 
slight facial paralysis passed off within a week. The discharge and 
dizziness soon disappeared. The middle ear was grafted five weeks 
later, the posterior wound closed and the patient made a good recovery. 

The peculiar features of this case are : 

(i) The involvement of the internal ear early in the course of an 
acute suppurative otitis media. 

(2) The avenue of infection was through the oval window. 

(3) The cause of the abducens paralysis by extension of the 
infection to the nerve sheath through the labyrinth seems probable on 
account of its rapid subsidence after drainage of the labyrinth was 
established. 

(4) The prompt recovery after drainage was established suggests 
that it was not necessary to remove the inner tympanic wall and com- 
pletely curet the inner ear. 

(5) The conclusion seems reasonable that the occurrence of abdu- 
cens paralysis in acute suppurative otitis media means an inward 
invasion of the infection, and when accompanied by the above men- 
tioned symptoms operative rather than palliative treatment should be 
applied to the tympanic cavity. R. b. c. 



LARYNGOLOGY. 

By WILLIS SIDNEY ANDERSON. M. D.. Detroit. Michigan. 

AaSBTAMT TO TMB CMAIB OF LASTMGOLOGT IN THE PBTKOIT COLLBGB OF MBDICINB 



THE ETIOLOGY AND TREATMENT OF MYCOSIS OCCUR- 
RING IN THE UPPER RESPIRATORY TRACT. 

Under the above title, Doctor John Sendziak, of Warsaw (Annals 
of Otology, Rhinology and Laryngology, December, 1905), gives an 
exhaustive review of the subject. He states that the following are 
the particular varieties of mycoses met with in the upper respiratory 
tract : 

(i) Mycosis leptothricia : causative agent — leptothrix bacillus. 

(2) Mycosis sarcinica : causative agent — ^a variety of the sarcina. 

(3) Actinomycosis: the causative agent being the actinomyces. 

(4) Mycosis aspergillosis : caused by various kinds of aspergillus. 

(5) Mycosis mucorina: produced by certain varieties of mucor. 
This, according to some authors, causing the so-called "black-tongue." 

(6) Mycosis oidica (soor) : caused by the oidium albicans. 

The etiology of mycosis leptothricia has not been positively decided. 
There exists two principal theories: (a) The parasitic, and (b) the 
chdmical theory. The advocates of the first theory believe that the 



226 ORIGINAL ABSTRACTS. 

causative agent is the leptothrix bacillus, while those who believe in 
the second theory hold that the organism is merely incidental to chem- 
ical changes in the secretions. 

Mycosis leptothricia is relatively more frequent in females than in 
males. It shows itself in the form of pearly white, hard tufts or spots 
which are situated in the crypts of the faucial tonsils, the lingual tonsils, 
and sometimes seen in the follicles of the posterior pharyngeal wall. 
These tufts are strongly adherent to the adjacent tissue and are removed 
with difficulty, leaving a bleeding surface. 

The course of the disease is chronic, and the symptoms may be few, 
or none at all. The most common symptoms are a scratching, pricking, 
burning sensation in the throat, accompanied by a disagreeable sensation 
of stiffness and fullness. 

The most satisfactory treatment is the thorough use of the curet 
or the galvanocautery to eradicate the disease. General tonics should 
be given. 

Mycosis sarcinica occurs in the upper respiratory tract on the 
mucous membranes of the oral cavity in persons who suffer from 
diseases of the lungs, pneumonia, bronchiectasis, gangrene, and espe- 
cially in persons suffering from tuberculosis or typhoid. This parasite 
is found on the mucous membrane of the tongue, as well as on the soft 
palate, in whitish diffuse masses similar to mould. This form of myco- 
sis is of no special importance, and general symptoms are lacking. 

-Actinomycosis is more frequent in men than in women, and usually 
runs a chronic course. The disease is common in cattle, and may be 
transferred directly to man. The symptoms of actinomycosis of the 
upper respiratory tract consist, in general, of very violent pains in the 
region of the pathologic process. The disease is primarily located in 
the oral cavity, on the alveolar process of the lower jaw, causing perios- 
titis alveolaris. It may extend to the pharynx, producing great swell- 
ing in the palatopharyngeal region, with whitish-yellow nodules iden- 
tical in appearance to follicular abscess. 

The prognosis is not favorable, especially if the internal organs 
become affected by the metastatic processes. 

The treatment of actinomycosis of the upper respiratory tract is 
primarily surgical in nature. lodid of potassium internally seems to 
do good. 

Mycosis aspergillina in the upper respiratory tract is rarely seen 
The cause of this is undoubtedly due to the peculiarity of these organs. 
Persons working in tanneries, or those dealing in leather, are predis- 
posed to this disease, as leather is an excellent medium in which the 
development of the aspergillus occurs. 

Mycosis mucorina in the upper respiratory tract occurs but rarely. 
It appears in two forms: (a) Mycosis dependent on the mucor corym- 
bifer, and (b) mycosis depending on the mucor niger — the more usual 
form. The second form, the so-called "black-tongue," is not a rare 



SPIROCH.€TA PALLIDA IN SYPHILIS. 227 

condition. The clinical picture is a brown discoloration, or a hairy- 
black condition on the posterior part of the papillae circumvallatae. 

The treatment consists in the scraping away of the hairy material, 
as well as the use of alkaline gargles. 

Mycosis oidioa (soor, thrush) occurs usually in young children. 
The infection takes place from ingested objects, from nipples, and less 
frequently from the air, or the infection takes place through the phe- 
nomenon of partus. Thrush occurs as small, round, white spots, with 
small excavations in the center, easily removable at first, later, as the 
disease progresses, more adherent. These spots coalesce irregularly, 
forming a sort of membrane of dirty color, the underlying mucous 
membrane being red and swollen. 

Local cleanliness and general treatment is indicated in this disease. 



DERMATOLOGY. 

By WILLIAM FLEMING BREAK EY. M. D., Ann Arbor, Michigan. 

CLINICAL rROFBSSOK OF DBKMATOLOGT AND STmiLOLOGT IN THB UNIVBKSITT OF MICHIGAN. 

AND 

JAMES FLEMING BREAKEY. M.D., Ann Arbor, Michigan. 

ASSISTANT IN DBBMATOLOGY IN THB UN1VBB81TY OF MICHIGAN. 



SPIROCH^TA PALLIDA (SPIRONEMA PALLIDUM) IN 

SYPHILIS. 

The Lancet of March lo contains a symposium on the spirochaetae. 
The first article under the above title is concluded in the issue of March 
17. In this, Theodore Shennan goes into the history and literature of 
the search for the contagium of syphilis from the time of the sixteenth 
century. His search of the literature on the spirochaetae has been 
thorough. He records the works of Schaudinn and Hoffmann, and 
describes the spirochaeta pallida and spirochaeta refringens, methods 
of staining and differentiating. 

Spirochaeta pallida has been found in surface lesions, indolent 
buboes, in blood obtained by splenic puncture, in circulating blood in 
secondary syphilis and in various lesions of the inherent syphilitic. 
Levaditi considers congenital syphilis to be a spirillosis of the newly 
born. Efforts to find the spirochaeta pallida in tertiary lesions have, 
with rare exceptions, proved unsuccessful. In searching for spiro- 
chaetae numerous preparations should be made owing to their unequal 
and irregular distribution. 

Kiolomenoglou and von Cube found and demonstrated various 
forms of spirochaetae in nonspecific lesions. Hoffmann admitted their 
great similarity but claimed that they could be morphologically or 
tinctorially distinguished from the pallida. Hoffmann states that 
those found in carcinomata have blunt ends. 

Kraus and Prantschoff found that spirochaetae disappear from 
excised tissues within six hours. This is interesting in view of the 



228 ORIGINAL ABSTRACTS. 

generally accepted clinical fact that syphilitic virus removed from the 
body soon degenerates. 

Levaditi and Petresco found spirochaetae readily and in considerable 
numbers in the serum of induced blisters. 

Rona found the spirochaeta pallida in six out of twenty healthy 
women and in three out of eighteen healthy men. Similar results are 
reported by others. 

The syphilitic virus cannot pass through a porcelain filter. 

Statistics of the findings of numerous authors are given. 

Schaudinn found spirochaeta pallida constantly in seventy cases 
and in tertiary lesions as granular resting forms. 

Castellani and Wellman have found spihochaetae in yaws correspond- 
ing closely to the spirochaeta pallida. 

Various spirochaetae often much resembling the spirochaeta pallida 
have been found in hospital gangrene, in noma, gangrenous tonsillitis, 
vaccine pustule, carcinomata and various venereal and nonvenereal 
conditions and in the bone marrow and muscular coat of the small 
intestine from cases of severe anemias and carcinomatous lymphangitis. 
These various spirochaetae, as a rule, may be differentiated by staining. 

Attempts at cultivation have so far been unsuccessful, j. f. b. 



NEUROLOGY. 

By DAVID INGLIS, M. D., Detroit, Michigan. 

PKOFKSOR or NBKVOVS AND MBNTAL DISSASBS IN THE DBTROIT COLLBGB OP MBOICINB. 

AND 

IRWIN HOFFMAN NEFF, M. D.. Pontiac. Michigan. 

ASSISTANT PHYSICIAN AT THE BASTBPN MICHIGAN ASYLUM. 



"THE MENTAL SYMPTOMS OF CEREBRAL TUMOR." 

Doctor Phillips Coombs Knapp cites {Boston Medical and Sur- 
gical Journal, April 5, 1906) the opinion of others on the relation 
and frequency of mental symptoms in brain tumors, and g^ves his statis- 
tics, which have proved to him that in ninety per cent of all cases of brain 
tumor mental symptoms can be noted. He reiterates his statement made 
some years ago that in every case some mental change can be found 
by a competent observer who has known the patient before. In other 
words : there can be no gross lesion in the brain without some disturb- 
ance, greater or less, in the physical functions. He, however, modifies 
the dictum to this effect : that in every case of brain tumor some mental 
symptoms can properly be discovered, at least by a competent observer 
who has known the patient intimately before. Regarding the nature 
of the mental symptoms, Knapp says that his investigations agree with 
those of Schuster. Schuster's statistics are dependent upon a series of 
seven hundred seventy-five collected cases, and would indicate that 



THERAPEUTICS OF LUPULIN. 229 

while mental torpor and stupor are present in a greater proportion of 
cases, specific psychoses are not infrequently found. Thus of his 
seven hundred seventy-five collected cases, two hundred fifteen showed 
mental conditions analogous to recognized forms of mental trouble. 
The question of the relation of the seat of the tumor and the mental 
symptoms is given considerable space by the author. The statistics of 
collaborators are considered and a reference table comprising all of 
the author's cases is given. 

In conclusion he states that "in studying the early development of 
mental symptoms I have already indicated the relative importance of 
certain areas in the possible production of such symptoms ; but the fact 
that mental symptoms m^y arise from a growth anywhere within the 
cranium, forces upon us the conclusion that other factors beside the 
location are of importance in their production." Knapp is unable to 
find any relation between the nature of the growth and the form of 
mental disturbance. He believes, however, that a rapidly growing 
tumor will more speedily cause mental symptoms than one of slow 
growth. He also infers from his study that "delirious" conditions are 
more apt to occur in cases of sarcoma. Attention is called to the 
resemblance between the mental symptoms met with in cases of brain 
tumors to those occurring in toxic psychoses. 

The writer believes that the cases under consideration reveal noth- 
ing as to the nature or even the existence of these toxins, but it seems 
probable that while the situation of the growth is often of influence in 
producing mental symptoms, especially in the early stages of the dis- 
ease, and possibly has an influence upon the nature of the symptoms, 
a combination of increased cranial pressure and the action of the toxin 
are of greater importance, and in some cases may be the only factor to 
be considered in the production of such symptoms. i. h. n. 



THERAPEUTICS. 

By DELOS LEONARD PARKER, Ph. B., M. D., Detroit, Michigan. 

LBCTVKBK ON MATKRIA IfBDICA IN THB DBTROIT COLLBGB OF MBDICINB. 



THE THERAPEUTICS OF LUPULIN. 

Doctor Thomas F. Reilly (The Journal of the American Medical 
Association, April 7, 1906) discusses the therapeutics of lupulin as 
brought out by an investigation made by himself and H. Stern, M. D., 
of New York. At the outset the statement is made that the purpose of 
the paper is to bring into view some of the old, and also some of the 
new, properties of one of the oldest agents in the materia medica. 

Attention is called to the circumstance that formerly lupulin was 
looked upon as almost a specific for scrofula, struma and the various 
skin diseases. 



230 ORIGINAL ABSTRACTS. 

Lupulin is derived in the form of scales from the hop plant. These 
scales contain lupulinic and humilic acids and a volatile oil. The taste 
of the drug is bitter. This is caused by amorphous hop resins rather 
than by alkaloids. Lupulin to be of value must be derived from the 
best Bohemian hops. It must also be fresh and have undergone no 
exposure to light or heat. 

The active principle of lupulin is closely related to valerianic acid. 
Taken by the mouth lupulin causes a sense of warmth first in epigas- 
trium and later over whole abdomen. It is a mild diuretic and in some 
persons lowers the pulse rate from ten to twenty beats a minute. The 
properties of the drug to which Doctor Reilly desires particularly to call 
attention are its hypnotic and anodyne properties. In twenty-grain 
doses repeated in a half hour it has a strong tendency to produce sleep 
and also to relieve nervousness, particularly that following excesses. 

As a pain-relieving agent it is to be classed with the milder anodynes. 
This property makes it of value in the colics of children, in acute pros- 
tatic disease and in neurasthenia and hysteria. It is also of value in 
headache, especially of the occipital variety, and in the pains of menstru- 
ation when not caused by pathologic lesions. 

In its administration aromatic spirits of ammonia forms a good 
vehicle for a liquid preparation. It may also be mixed with sugar when 
it is given to children. Generally, however, it is best administered* in 
capsules. It can be substituted for opium in treating children and for 
the coal-tar products in many instances. Indeed, its property of meet- 
ing the conditions wherein a coal-tar product is often thought to be 
indicated is considered by Doctor Reilly to constitute its chief claim to 
the attention of the profession. This view is shown by the following 
quotation taken from the closing portion of this paper : 

"In this era of a high-tension civilization the practitioner is not 
infrequently brought face to face with the treatment of pains and aches 
and insomnias which are not in themselves severe and do not have any 
organic disease as a cause. These patients are neurotic and high strung 
and are not suffering enough to demand the use of an opiate, and yet 
in these very people habits are easily formed. The coal-tar series of 
the past decade has seemed the surest way out of such a dilemma. The 
laity know it as well as we do and act accordingly. Now that the 
formation of a coal-tar product is generally recognized, it will probably 
be a major problem in the next generation. Any one who has seen the 
cyanosis, palpitation, et cetera, following the use of any of these agents 
in some people must conclude that they are not in any case without 
some harm, however slight it may be. In many of the cases described 
above in which we are tempted to use the coal-tar series, we may sub- 
stitute lupulin and we may go home and sleep soundly, confident that 
the patient will have been, in a measure, relieved and that he will not 
be found dead in bed the next morning as has not infrequenty happened 
when an acetanilid powder has been taken to soothe his nervous 
complaints." 



CONGRESS OF PHYSICIANS. 231 

EDITORIAL COMMENT. 



THE PORTUGUESE INTERNATIONAL CONGRESS OF 

PHYSICIANS. 

Lisbon afforded every desideratum to render the recent Fifteenth 
International Medical Congress a complete scientific and numerical 
success barring the Latin tongue and a lack of delegates. The former 
militated against a cosmopolitan participation in the discussional work 
of the sections, while the latter essential was not in evidence to marked 
degree, registration showing the presence of only about sixteen hun- 
dred, fifty of whom were from the United States. The idea of two 
successive Latin congresses was not calculated to insure international 
attendance, and a practical test of the experiment has demonstrated 
that the delegates hailed principally from Portugal, Spain, and other 
countries in which the vernacular contemplates Latin derivation. 

* * * 

The Congress was convened by King Carlos on Thursday, April 
19, and continued its sessions through the week ending April 26, the 
address of welcome, an interesting discourse, being read by His 
Majesty in French. The speaker was supported on either side by 
Queen Amelie and the Queen Dowager, the former, by the way, being 
a regular physician, a trained nurse, and one of the most intellectual 
women of the age. The general addresses reflected the present status 
of practical medicine and surgery. Aaser, of Christiania, detailed the 
"Relations of Acute Infectious Diseases With Tuberculosis"; Boyce, 
of Liverpool, discussed "The Prophylaxis of Yellow Fever as the 
Result of the 1905 Epidemic in Central America and New Orleans; 
Brissaud, of Paris, talked on "Infantilism"; Crocq, of Brussels, 
described "The Mechanism of Reflexes and of Muscular Tonus" ; von 
Hansemann, of Berlin, revealed "The Significance of Domestication 
for Diseases of Animals and Man"; Neumann, of Vienna, related 
"The Anatomic Causes of Syphilitic Relapses and Methods to Follow 
to Combat Them" ; Reclus, of Paris, discoursed on "Local Anesthet- 
ics" ; de TarchanoflF, of Saint Petersburg, recounted the possibilities of 
"Radium in Biology and Medicine, or Organotherapy of Our Days" ; 
while our own Senn, of Chicago, made "A Plea for the International 
Study of Carcinoma." The programs of the twenty different sections 
afforded abundant material for consideration, in fact more than could 
be properly discussed during the sessions notwithstanding many of the 
titles listed were unsupported by paper or author. The total number 
of essays and addresses announced was two hundred fifty, representing 
one hundred forty different subjects, but comparatively little very new 
was added to our store of knowledge. The operation of Gigli, cutting 
the iliac bone, was offered as a substitute for symphysiotomy. Frank 



232 EDITORIAL COMMENT. 

recommended a suprapubic, extraperitoneal Cesarean operation, claim- 
ing superiority for this procedure, especially in septic cases. The 
American operation for fibroids received endorsement. Discussion 
concerning yellow fever elicited expression of doubt as to mosquitoes 
being the only cause of the scourge. Tuberculosis received attention 
commensurate with the importance of the subject, Bernheim urging 
the appointment of an international prophylactic commission to draft 
a code of regulations bearing on the disease. 

♦ ♦ ♦ 

The social features of the event were numerous, some being 
decidedly elaborate. The various functions included receptions, din- 
ners, garden parties, excursions, bull fights, et cetera. The dinner 
tendered by the King was a brilliant affair. It was attended by one 
hundred fifty official delegates, court officials, and ambassadors, who, 
together with the King, Queen, Queen Dowager, diplomats, and mili- 
tary officers increased the number to two hundred. The American 
delegates were tendered a dinner by our representative at the Court of 
Lisbon, Charles Page Bryan, covers being spread for fifty guests. 
The King and Queen gave a garden party in the royal grounds, and 
the Marquis of Montserrat treated the guests to another garden party 
in his grounds at Cintra, while a reception was tendered by the city 
of Lisbon at the Hotel de Ville. 

The next meeting will be held at Budapest three years hence, the 
Hungarian invitation having been backed by a governmental appro- 
priation of fifty thousand dollars. 



ANNOTATIONS. 



THE TREATMENT OF CANCER WITH TRYPSIN. 

Probably no disease is fraught with more disastrous consequence 
than cancer. Although the medical treatment of the malady has hith- 
erto been of a somewhat empirical nature, the result of recent experi- 
ment would seem to indicate that the etiology and therapy of the 
growth will soon be known factors. Speculation bearing on the cause 
has given rise to both humorous and scientific theories, and among 
the latter that of Beard, of Edinburgh University, seems sufficiently 
meritorious to elicit comment. Beard contends that migrating cells 
exist in all parts of the organism and that under normal conditions 
they are merged with the fixed cells of the body. However, in certain 
disease conditions, from causes at present undetermined, the wanderer 
fails to unite with a fixed cell, thus becoming foreign and producing 
the malignant growth — cancer. This view is a slight modification of 
Cohnheim's theory, but Beard has augmented the hypothesis by ven- 
turing the assertion that the growth may be directly traceable to the 



RACE SUICIDE. 233 

absence of some systemic product — a substance which is calculated to 
destroy the malicious nature of the aberrant cell and convert it into 
normal tissue. Beard being an embryologist, has had abundant oppor- 
tunity to study various forms of life in developmental stages, and has 
observed that immediately upon the establishment of the pancreatic 
function in fishes the wandering cell disappears. Using this phenome- 
non in the fish as a possible clue upon which to establish a logical treat- 
ment, Beard employed trypsin in cancerous mice with apparent good 
result, the wandering cell disintegrating and leaving the normal cell 
unimpaired. The product has been used to some extent on human 
l>eings with the idea of preventing recurrence of the disease after 
operation, and from all appearances the effect has been gratifying. 



THE DEMISE OF PROFESSOR CURIE IN PARIS. 

Professor Curie, who with his wife shared the honor of giving to 
science a new chemical element — radium, died on April 19, from 
injuries sustained in a collision with a vehicle in the streets of the 
French metropolis. Curie married a Polish woman/ a profound stu- 
dent of science, who had been a worker in his research laboratory, and 
after six years of conjoint and untiring labor their discovery of radium 
was announced in 1898. The nature of the element upset some of the 
supposedly fixed chemical hypotheses such as the atomic theory and the 
theory of the conservation of energy, and the enthusiasm of certain 
therapeutists for a time gave the product undue prominence in the 
domain of medicine. In 1903 Professor Curie received, in conjunc- 
tion with his wife, the Nobel prize for scientific research, and in the 
same year Madam Curie was awarded the Osiris prize of $12,000. 
That the usefulness of radium and many of its properties had not been 
determined. Curie was convinced, and he was deeply absorbed in 
research at the time of his premature demise. In his death the world 
lias lost a man of vast scientific attainment and one who was calculated 
to revolutionize certain fields of science. A widow and child eight 
years old are immediate mourners. 



DOCTOR REED ON RACE SUICIDE. 

Contrary to the views of President Roosevelt on the race suicide 
' -question, are those of Doctor Charles A. L. Reed, of Cincinnati, who 
argues that few children properly reared will better subserve the 
common weal than many children developed in unsuitable environ- 
ment, the idea being that conditions of creature are paramount to 
commands of creator. In the course of a lecture on the "American 
Family" the doctor said: "We see in a declining birth-rate only a 
natural and evolutional adjustment of race to environment — an 
adjustment that insures rather than menaces the perpetuation of our 
kind under favoring conditions." Race suicide consequently implies. 



234 EDITORIAL COMMENT. 

according to the speaker, not aversion to conception, but an unselfish 
regard for the proper development of the offspring. Continuing, 
Doctor Reed said: "American women recognize, subconsciously, pos- 
sibly, certainly not in definite terms, but they nevertheless recognize, 
the force of the law enunciated by Mr. Spencer that whatever conduces 
to the highest welfare of offspring must more and more establish itself, 
since children of inferior parents reared in inferior ways will ever be 
replaced by children of better parents reared in better ways." 



CONTEMPORARY. 



•PHYSICIANS AND PHILOSOPHERS. 

[PKOFBSSOR CHARLBS WILLIAM SUPBK, OP OHIO UNIVBRSITY, IN POPULAR SCIKNCB MONTHLY.] 

{CoHiiHU*d from page qi.) 

It will scarcely be denied by those best qualified to judge that of 
the three learned professions that of medicine is still the best fitted 
to stimulate thought and investigation. It is less hemmed in by 
tradition, and is of immediate public interest. The man who conquers 
a dangerous disease or who performs a difficult surgical operation 
needs no other endorsement. Unless he allows avarice to draw him 
into a practice more extensive than his constitution will bear, he will 
have a fair degree of leisure for liberalizing his mind by the study of 
subjects outside of his particular sphere. The history of modem 
times no less than that of antiquity offers many examples of medical 
men whose interests were almost coextensive with those of mankind. 
That the physician, the investigator, the philosopher and the litterateur 
may be happily blended in one person is finely illustrated by the latest, 
though it is to be hoped not the last, volume either of the man or of 
his kind, the *Aequanimitas' of Doctor Osier. 

No one who is acquainted with human nature will be surprised 
when he learns that the class of medical practitioners known as 
'quacks' flourished among the comparatively enlightened Greeks of 
ancient times. Often, however, the quack is one who strives after 
results by a method that has been tabooed by the corporation to whose 
regulations it is assumed that he ought to have subscribed. Though 
he is an outlaw, before the tribunal of mortals he may be just as good 
as if he were an in-law. That mysterious and apparently inscrutable 
part of our being known as the nervous system has always presented 
problems which medical practitioners have been unable to solve. Why 
should not a faith-cure be as legitimate as any other cure, provided it is 
genuine? And there have been faith-cures time out of mind. When 
persons cannot control their own imaginations, the task would seem to 
be doubly difficult for any one else. Often the most important part 
of the physician's business is to arouse in his patient the will to get 
well, and whatever will accomplish this cannot be stigmatized as fraud. 



PHYSICIANS AND PHILOSOPHERS. 235 

When hope is lost all is lost. I have known not a few persons who 
died because they did not want to live or were at least indifferent ; and 
probably an equal number who materially lengthened their lives by 
the mere determination not to die. My attention was drawn to this 
phase of pathoIog>' many years ago by a curious incident that came 
under my observation when I was a mere lad. I did not hit upon the 
explanation until long afterwards. I have seen the same thing 
repeated many times since then. A vender of medicaments of his own 
concoction used to visit our neighborhood about twice a year. One 
day as he was driving along he began to feel unwell, and, contrary to 
the proverb that doctors never take their own medicines, picked from 
fiis chest a vial containing what he believed would afford him relief, 
and drank some of its contents without looking at the label. Having 
occasion shortly afterward to leave his wagon to visit one of his cus- 
tomers, it occurred to him that he had drunk from a bottle containing 
a strong poison. He at once began to feel very sick. A sort of stupor 
seized him and he became so weak that he could hardly walk. As 
soon as he could get back to his medicine-chest he looked at his bottles 
again, when, to his great joy and greater relief, he found that he had 
taken just what he intended. The man declared afterwards that he 
believed he would have died if he had not had the means of ascertain- 
ing the facts in the case. 

Though the ancients knew little of the structure of the nerves, they 
were well aware of the influence of the imagination as a therapeutic 
agency. The walls of many of their temples were covered with tablets 
and votive offerings in testimony of gratitude to the god by whom the 
sick were healed. Faith-cures and christian science are therefore by 
no means a new thing under the sun, but something very old under 
new names. Though the ancients rarely, or not at all, dissected 
human bodies, they had a fairly definite knowledge of anatomy derived 
from the inspection of brutes. The bony structure could be readily 
studied with the aid of the skeletons that were plentiful enough in 
countries dotted with battlefields. The Persian invasion alone proba- 
bly left tens of thousands of corpses strewn along the retreat of the 
great king. The aversion to the dissection of cadavers that was felt by 
many of the Greeks seems to have been connected with their reverence 
for the human form. It was regarded as a sacrilege to mutilate even a 
corpse. The treatment which the dead body of Leonidas received at 
the hands of Xerxes was due, as Herodotus expressly informs us, to 
the extraordinary exasperation he felt against the Spartan king for his 
fierce resistance to the Persian advance. Though Achilles had dragged 
the dead body of Hector many times around the walls of Troy, yet 
Apollo preserved it uninjured. This reverence for the *human form 
divine,' like many others superstitions, interfered seriously with the 
progress of science. The favorite gods, Zeus and Apollo, were repre- 
sented as physically perfect men. The effects of this sentiment are 
especially evident in the manner by which those condemned to death 
were executed. There seems to be no other explanation of the singular 



236 MEDICAL NEWS. 

custom of administering the hemlock juice than the desire to leave the 
body after death as nearly as possible as it appeared in its living state. 
That the rule was departed from under special circumstances and in 
times of great excitement is no valid argument against the correctness 
of the explanation. 

[TO Bl CONTINUBD.] 



MEDICAL NEWS. 



A GRIST OF MEDICAL GRADUATES. 

The thirty-eighth annual commencement exercises of the Detroit 
College of Medicine were held in Light Guard Armory, Thursday even- 
ing, May 17, 1906, when eighty-two candidates received the degree of 
Doctor of Medicine. The address of the occasion, which will be pub- 
lished in the next issue of this journal, was delivered by Doctor Frank 
B. Walker. After the award of diplomas a banquet was tendered the 
graduating class at Hotel Cadillac by the Faculty of the College. Fol- 
lowing is a list of those upon whom degrees were conferred : S. M. 
Angle, O. Amdt, A. W. Blain, Jr., G. K. Boyajian, G. T. Britton, C. W. 
Burge, J. F. Burleson, R. C. Burt, J. B. Chapman, R. L. Clark, C. W. 
Courville, F. L. Covert, R. E. Dawson, W. A. DeFoe, P. J. De Free, W. 
H. Dunham, G. A. Easton, O. A. Fischer, E. F. Fisher, F. G. Fisher, H. 
I. Flanders, R. R. Fox, H. E. Eraser, F. D. German, G. C. Griffis, J. L. 
Hammond, T. P. Hanna, J. H. Hanson, H. Harrison, L. L. Harrison, 
W. H. Haughey, Jr., L. E. Hemenway, J. H. Henry, C. F. Hinchman, 
W. Hipp, M. C. Hubbard, E. R. Johnston, W. G. Kanter, J. C. Ken- 
ning, H. I. Kedney, J. E. King, J. A. Klahs, B. G. W. Larke, R. W. 
Luce, J. F. McKay, J. C. MacKenzie, J. R. MacKenzie, C. L. D. Mc- 
Laughlin, A. R. Miller, F. B. Miner, L. Mueller, F, E. Murphy, C. H. 
Oakman, H. A. Osborn, H. A. Ott, W. C. Pepin, H. Pepper, M. E. 
Pickens, A. C. Potter, A. D. Potter, F. A. Pratt, S. W. Randoph, C. J. 
Rolhnan, D. U. Saunders, F. M. Singer, C. A. Smith, W. H. Snyder, 
R. E. Spinks, U. G. Spohn, C M. Stafford, T. C. Starrs, F. E. Stevens, 
H. A. Stewart, C. H. Stiles, J. E. Strain, F. M. Summerville, R. S. 
Taylor, F. Tremblay, E. C. Van Sickle, J. R. Van Sickle, W, J. Voor- 
heis, F. T. Zieske. 



MINOR INTELLIGENCE. 



The alarming increase of pneumonia in Indiana, and the large 
number of deaths incident to the disease, has instigated the issuance of 
a bulletin by the State Board of Health calling the attention of physi- 
cians to the prevalence of the affection, and admonishing them to 
instruct the laity as to its seriousness and the best means of combatting 
the dissemination of the pneumococcus. 



MINOR INTELLIGENCE. 237 

Doctor Emma Cook, a prominent women practitioner of Detroit, 
died of anemia on April 14, aged fifty-eight years. Doctor Cook was 
a graduate of the University of Michigan, with the class of 1892. 

A MEMORIAL service was held in Berlin on April i, to commem- 
orate the death of Doctor Max Nitze, the inventor of the cystoscopy 
An exposition has also been conducted showing the various stages of 
development in the instrument, and the material originally employed 
by Nitze. 

The American Gastroenterologic Association will meet in Boston, 
June 4 and 5, 1906. The president's address will be delivered by 
Doctor Henry W. Bettmann, of Cincinnati, on "The Mutual Obliga- 
tions of the Surgeons and Internists in the Proper Development of 
Gastric Surgery." 

The Ohio State Medical Society met at Canton on May 9, for a 
three days' session. An interesting and instructive program was pre- 
sented. The oration in Medicine was delivered by Doctor John C. 
Hemmeter, of Baltimore; and that on Surgery by Doctor Harvey C. 
Gaylord, of Buffalo. 

Verily, this is an age of remarkable progress in medical thought 
and practice. A contemporary reports the case of a sightless Wash- 
ingtonian, to whom were transplanted the eyes of a Belgian hare. The 
operation is said to have been so skilfully performed that vision was 
completely restored! 

Professor van Ermenghem^ of Brussels, recently announced 
before the Academy of Medicine that he had proven almost conclu- 
sively the bacterial origin of cancer, and further stated that the results 
obtained in a long series of experiments have led him to the belief that 
serum derived from the organism will cure the disease. 

Doctor Edward Anthony Spitzka, formerly connected with the 
Philadelphia College of Physicians and Surgeons as demonstrator of 
anatomy, has been elected to the professorship of general anatomy 
in the Jefferson Medical College. Doctor George McClellan will 
occupy the chair of applied anatomy at the same institution. 

The Christian Hospital, of Chicago, an institution of undetermined 
reputation, was recently fined $250 for publishing, without sanction, 
the name of Doctor John B. Murphy as president of its executive board. 
The hospital authorities persisted in their employment of the name, 
regardless of the fact that Doctor Murphy secured an injunction 
restraining them from so doing, hence the penalty. 

Over a million circulars of warning have been distributed during 
the past two years by the German Society for the Prevention of Vene- 
real Disease. The campaign has been very thorough, physicians, dis- 
pensaries, and the army being the agencies through which the dis- 
tributions were effected. It is the purpose of the society to issue a 
similar circular to women and young girls during the coming year. 



238 MEDICAL NEWS. 

Smallpox has wreaked havoc in Chile during the past year, the 
country having been literally infested with the pest. Since January, 
1905, more than eleven thousand cases and five thousand deaths have 
been recorded — a powerful argument against the existing sanitary 
regime of the South American republic. 

Andrew Carnegie has deviated from the path of library endow- 
ment by promising the sum of $10,000 to the College of Physicians 
and Surgeons, of Atlanta, Georgia. The college trustees are desirous 
of raising $100,000 for the purpose of erecting new buildings, and the 
steel magnate's gift will be the last $10,000 of this amount. 

New York is suffering from an epidemic of diphtheria, and new 
cases are daily recorded. The percentage of deaths from the disease 
has become so high that Health Commissioner Darlington has issued 
an appeal to both laity and profession for a more generous employment 
of antitoxin. At present the death rate is fourteen per cent. 

The commission in charge of the Michigan Sanatorium for Con- 
sumption has chosen a site two and one-half miles from the city of 
Howell. The location is an ideal one, since it possesses excellent nat- 
ural advantages, being at an elevation of one thousand one hundred 
feet above sea level, and having running water, timber and a lake. 
The property, one hundred ninety acres, was presented by the city of 
Howell. 

A committee composed of American and European physicians has 
been formed to solicit and receive subscriptions for the erection of a . 
monument to the late Surgeon Miculicz-Radecki, of Breslau. W. W. 
Keen, of Philadelphia; W. S. Halsted, of Baltimore; J. B. Murphy, of 
Chicago; and F. Kammerer, of New York, comprise the quartet of 
Americans who will represent the work in the United States and 
Canada. 

The establishment of a new filtration plant in connection with the 
Jerome Park reservoir, New York, is being agitated, the city com- 
missioner having submitted preliminary plans to Mayor McClellan. 
The present move was instituted to offset the plans of a rival faction, 
whose idea contemplated the purchase of a new site, which, together 
with the cost of building the filter, would indebt the city to the extent 
of $8,500,000, according to a very low estimate. The plan of the 
present projectors is to utilize the park property for the enterprise. 

The consolidation of the Medical College of Indiana, the Central 
College of Physicians and Surgeons, and the Fort Wayne School of 
Medicine has been effected, and the trio will henceforth form a com- 
ponent part of the Purdue University at Indianapolis. In a circular 
announcing the change, the executives of the several colleges explain 
the reason therefor by stating that a concentration of interests in a city 
of sufficient size to offer ideal clinical facilities will best conserve the 
interests of all concerned — students and teachers alike. The consolida- 
tion was effected after an agfitation covering a long period of years. 



DIFFERENTIAL DIAGNOSIS. 239 

A WOOD alcohol debauch is responsible for one death and the serious 
illness of several prisoners confined in the military prison at Governor's 
Island. The product was undoubtedly secretly conveyed to the in- 
mates by visitors. The deleterious results ensuing from the employ- 
ment of wood alcohol, even in commercial pursuits, has led to the intro- 
duction of several bills before the House Committee on Ways and 
Means at Washington, for the removal of the internal revenue tax on 
grain alcohol for industrial purposes. Painters and varnishers are 
especially subject to the vapors of the wood product, and a chair 
finisher who lost his eyesight from this cause appeared before the com- 
mittee to support the measure. 



RECENT LITERATURE. 



REVIEWS. 



DIFFERENTIAL DIAGNOSIS AND TREATMENT OF 

DISEASE.* 

If the title of this book is comprehensive, the contents are no less 
so. This includes : "The Technique of Diagnosis and Laboratory Aids 
to Clinical Diagnosis," 55 pages; "General Therapeutic Management," 
pages 55-87; "Pediatrics," 87-229; "The Digestive System," 229-332; 
"Circulatory System," 33-409; "Respiratory System," 409-469; "Gen- 
ito-Urinary System," 469-533; Osseous, Muscular and Articular 
System," 533-602; "Infectious and Contagious Diseases," 602, 643; 
"Diseases Due to Faulty Metabolism, Faulty Internal Secretions and 
Derangement of Ductless Glands," 643-675; "Nervous System," 675- 
769; "Dermatologic Memoranda," 769-806; "Otic Memoranda," 806- 
812; "Ophthalmic Memoranda," 812-823; "Anesthesia, Intoxications, 
Miscellaneous Ailments, Keeping Case Records and Accounts," 823- 
838. This classification seems somewhat arbitrary, but may have some 
practical advantages that have not made themselves apparent to the 
reviewer. Similar reasons, probably, have placed "dysentery" in the 
chapters on "Pediatrics and Digestive System," lobar pneumonia and 
tuberculous pneumonia" in the "Respiratory System," et cetera. A 
more orderly though less "practical" classification, with a good index, 
would have answered the practical need just as much, and would almost 
certainly have saved space. 

As for the text itself, the author has acquitted himself well of a 
task that at first sight seems almost impossible. That is, he has given 
some directions regarding each of the numerous topics included in 



240 RECENT LITERATURE. 

his scheme. Necessarily these are brief, in many cases so brief as to 
make the work more useful for hurried reference in an unexpected 
time of need, rather than for thorough information, such as the prac- 
titioner, or even the advanced student, should have. The views of the 
author are on the whole sound, often admirable. The introduction 
should be read by all who are preparing for the medical course. Other 
indications of the high principals held by the author are often encoun- 
tered through the text, and do not seem to suffer from occasional jux- 
taposition with recommendations of remedies not yet admitted to the 
"United States Pharmacopeia." In general, too, the directions for 
diagnosis and treatment are sound, though lapses are not infrequent. 
The author's tendency to look for and treat a malarial complication 
takes one back to the preplasmodial days. His opinion of the value 
of waxy casts — to indicate chronic rather than acute processes — is cer- 
tainly wrong. In some of the technical directions haste has led to 
omissions, sometimes important for beginners, as in the descriptions 
of blood stains, page 44, the preparation of aniline water, and others. 
Sometimes the omissions are tantalizing, as when we are told (page 52) : 
"There are peculiar cell reactions so that we can determine which cells 
come from primary and which from secondary tumors," without further 
descriptions of the alleged reactions. Repetitions are notably frequent. 
Antique beliefs are sometimes resuscitated, as in the assertion of the 
diagnostic importance of Sanirelli's bacillus. lodophilia seems unduly 
exalted and its history set forth with details that would gain by refer- 
ences to original articles. 

The directions for treatment are in the main good, but usually are 
too brief for anything but momentary use. Typhoid fever has a little 
over two pages ; pneumonia not much more than one page on treatment. 

The work is profusely illustrated, but many of the pictures belong 
to the realm of portraiture rather than medicine. If one must have a 
cut of a stomach tube it would seem better to picture that sort in general 
use. The cut labelled "bronchocele," and also the description, seem to 
limit the use of that term to bronchial cyst, which is certainly not cus- 
tomary. The position of the patient blowing bottles is not one that is 
likely to further the result desired. 

On the whole, while the plan and scope of the book are good, it 
requires considerable alteration before it can be recommended for 
undergraduates. For the practitioner who knows enough to avoid the 
mistakes, it will be interesting; to others it might be dangerous if fol- 
lowed blindly. It is to be hoped the necessary corrections may soon 
be made, so that the work will all be as good as its best parts. 

G. D. 

*A Text-Book for Practitioners and Advanced Students. By 
Augustus Caille, M. D. With two hundred and twenty-eight Illus- 
trations in the text. New York and London : D. Appleton & Company, 
1906. 



% itesician aulr Swrgeon 

A PROFESSIONAL MEDICAL JOURNAL. 



VOLUME XXVIII. JUNE, 1906. NUMBER VI. 



ORIGINAL ARTICLES. 



ADDRESSES. 



PRACTICAL DISCOURSE TO EMBARKING PHYSICIANS.* 
By frank B. walker, Ph. B., M. D., Detroit. 

AOJimCT ntOFBS60R OF ftUKGUlY IN THB DBTKOIT COLLBGB OF MBDICINB. 

Mr. President, Associates on the Faculty, Members of the Graduating 
Clctss, Ladies and Gentlemen: 

It is now thirty-eight years since this college first opened its doors 
to aspiring students of medicine. It is not long in point of time, but 
from the viewpoints of work done and of medical progress, the vista 
is broad and inspiring. Classes have come, pursued the round of col- 
lege life, and gone, until already more than seventeen hundred and fifty 
students have passed before the eyes of a critical faculty and taken up 
the practice of medicine and surgery in thirty-nine of the United States 
and in many places abroad. Think of the hours of study and the efforts 
to teach which this army of trained men represent; calculate in your 
mind the services of each alumnus and the sum total of them all in the 
interest of life and health ; picture if you can the want of all this pro- 
fessional skill, the kindly offices of all these devotees to duty, and then 
will you not place a high and lasting regard upon the results achieved 
through the instrumentality of this institution ? 

Thirty-eight years ago medical education, in spite of a hoary past, 

was in a very rudimentary stage of development. No one of us may 

hope to see the science perfected, and yet those who have lived the last 

two scores of years, have witnessed greater advancement in the science 

and art of medicine than all the Methuselahs of the past combined. 

It is not my purpose to laud this faculty or to proclaim its policy, but 

results have demonstrated the effect of honest and earnest endeavor 

^Address before the graduating class of the Detroit College of Medicine, 
Thursday evening, May 17, 1906. 



242 ORIGINAL ARTICLES. 

ev^n when unaided. Year by year saw added responsibilities put upon 
the college if she would do her full duty to those confiding in her nur- 
ture, and maintain a high standing among her sister institutions. These 
she promptly and cheerfully assumed by from time to time lengthening 
the course of study and enlarging its scope, by erecting larger build- 
ings, installing and thoroughly equipping new laboratories, and withal 
voluntarily raising the standard of admission even though it materially 
cut down the income. All this has been accomplished without state, 
denominational, or other outside help, without any adequate financial 
remuneration or return for the energy expended, and often at a pecuni- 
ary loss to those engaged in the work. You may ask then the reason 
or need for all this labor and sacrifice. For answer I would again 
point to the results obtained, the charity bestowed, for in truth it is the 
benevolence of the work that made it live and prosper. 

We have gathered here tonight, in keeping with a custom of our 
own, for the twofold purpose of recognizing publicly and authorita- 
tively the completion of required medical study, and of speaking and 
responding for the last time as faculty and students. You, members 
of the graduating class, have for the past four years cast your lot with 
us. Whether or no you thoughtlessly at first chose your Alma Mater 
we do not know ; but you knew at least that this college was particular 
as to who and what you were. Now that you have remained with us 
through to the end, and inasmuch as you are the sons not of Michigan 
alone but of at least eight different states, we take it that your residence 
here has been worth while. 

As the mother-bird makes a nest wherein to rear her young, and as 
she nurtures and protects them through the days of growth, then, when 
they shall have attained due strength, pushes them from the nest to 
try their wings in flight, now guiding and now supporting them, so 
your Alma Mater, after thorough education and trial of your strength, 
proud of your attainments, opens again her doors and leads you forth 
to do your part in the world's work. Life is longer than a generation ; 
duty is for everyone ; you have been drafted today. 

Before dissolving the relations of the past four }-ears it becomes 
us, who have been in the larger school of experience, to give you form- 
ally a few words of counsel on matters not included in the schedule of 
instruction. In the first place let me warn you not to be deceived by 
present appearances. As at your christening and on your wedding day, 
so now you are the cynosure of all eyes. You have just completed a 
long, difficult, and meritorious course of study and are about to be 
crowned with the laurel wreath of victory. But, unlike the victor in 
the games of Apollo, your real work is not done. You are merely 
prepared to take it up. In the school of instruction you have been fos- 
tered, excused, and protected. In the school of experience, of which 
Father Time is president, you will have to be solicitous, self-reliant, 
and courageous. Work is the law of our being. That law has greater 



DISCOURSE TO EMBARKING PHYSICIANS. 243 

significance for you today than ever before. With your increased 
abilities and higher aspirations difficulties will be greater rather than 
less. You will have opportunities galore but you will also find as many 
others beside you seeking to take advantage of them. The question for 
you then is how to succeed. It is not expected of me as the spokesman 
of the faculty, nor is it fitting on this occasion to descant on character 
as a text, but you should ever bear in mind that high ideals are essential 
to great success. If you were to ask me to state in a word how to attain 
success I would answer, deserve it. 

The first practical question that will come up in your minds will be 
where to locate? I know very well that advice on this point is seldom 
heeded. Everyone likes to find his own niche if possible and is willing 
to follow advice only in case it coincides with his own wishes. One 
injunction above all others on this subject, however, you should be 
given. Do not buy out another doctor's practice. There may be good 
reasons for selling and the location may be desirable, but the holding 
of the good will and support of another doctor's patients is very differ- 
ent from purchasing the good will of the doctor himself. Only recently 
a letter was received from a physician in the State of Washington, who 
asked only fifteen thousand dollars for his practice in a town of two 
thousand. 

Another matter upon which it is customary to give advice to young 
physicians is that of marriage. Seven years ago we heard a member of 
this faculty — strange to say, still a bachelor — ^in speaking from this 
platform, declare that he doubted the patriotism of a man who does not 
marry. I have seen many classes go out from this institution but I 
have never seen one whole class depart in single blessedness. This 
class has not been rigidly polled, but I have been told that there are at 
least sixteen benedicts in it already, and another can scarcely wait until 
tomorrow to sing like a lark the bliss of married life. From my own 
observation I believe that most men need no encouragement to marry. 
They might, however, well take advice in regard to the choice of a 
wife. Burns is credited with having divided the qualities of a good 
wife into ten parts. Four of these he gave to good temper, two to good 
sense, one to wit, one to beauty — such as a sweet face, eloquent eyes, 
a fine person, a graceful carriage ; and the other two parts he divided 
among the other qualities belonging to or attending on a wife — such as 
fortune, connections, education (that is of a higher standard than ordi- 
nary), family blood, et cetera; but he said : "Divide those two degrees 
as you please, only remember that all these minor proportions must be 
expressed by fractions, for there is not any one of them that is entitled 
to the dignity of an integer." 

When you shall have located you will do well to ally yourselves 
with the local fraternity by joining the county and state medical soci- 
eties and attending their meetings. By so doing you will acquire some 
of your best friends, aid your establishment in the community, and 



244 ORIGINAL ARTICLES. 

obtain the benefit of postgraduate study at home. It goes without say- 
ing that an active participation in the affairs of these organizations will 
secure the best results. 

Your relations with your fellow-practitioners should be ef the most 
cordial character. For your own sake do not be a "knocker." A doc- 
tor in an inland town recently told me of a fellow-practitioner with 
whom no other doctor in the vicinity would consult because of his 
unfair dealings. His aim seemed to be to disparage the abilities and 
methods of others. To my knowledge that particular "knocker" has 
already moved twice. 

"The Principles of Medical Ethics," recently placed in your hands 
through the courtesy of the American Medical Association, indicate the 
correct line of conduct toward patients, fellow-practitioners, and the 
community, and though they are intended to be advisory merely they 
are well deserving of thoughtful study and adoption. 

It is not supposed that any of you have taken up the profession of 
medicine as a money-making business. If so, there are more than nine 
chances in ten that you will be disappointed. You should, and doubtless 
will, obtain a competent living, and earn much more for which you will 
receive your reward in the hereafter. You will sometimes have to be 
satisfied without even the gratitude of patients to whom you shall have 
rendered valuable services. It will be gratifying to find, however, that 
most people expect to pay for value received. Follow the Golden Rule 
in your conduct and you will usually be treated in like manner. Ek) 
not be cast down if you should learn that your patients have consulted 
a rival. It may be that even at that moment some of your rival's 
patients are on their way to consult you. Be just to yourself. You 
need not expect to satisfy everybody or anybody always. Your individ- 
uality, if you have any, will not make it possible. Be dignified. Place 
a proper estimate upon your own services and do not underrate them 
by beating down your colleague's fees. Remember that you can never 
build yourself up on a substantial foundation by in any manner under- 
mining any other person, be he physician or layman. 

There has sprung up during the past few years the practice of 
"dividing fees." It is essentially a brokerage business, and is on a 
par with the practices of "runners" in "bath cities." Inasmuch as the 
entire transaction is done without the knowledge of and nevertheless 
at the expense of the patient, it becomes unscrupulous and ends in a 
skin game. The physician, who treats or examines and refers a patient 
to a specialist, should collect, for services rendered, from the patient 
himself and not from the consultant, and the specialist should not 
exhaust the patient's ability to pay the first physician's bill. This 
arrangement is natural, honorable, and equitable to all concerned, while 
graft-seeking and bribe-giving easily descend to a traffic in human lives. 

Lastly do not be a curiosity shop. Be alive to and interested in 
everything that attracts most men. Be public spirited. Be a politician 



LESSONS IN LONGEVITY. 245 

if duty requires, but remember that a busy, successful physician and a 
politician are never one and the same person. Your profession must 
be your first and chief occupation — ^your true vocation. That does not 
mean, however, that you should not have an avocation as well. Take 
time to live. You owe it to yourself, to your family, friends, everybody. 
The time has now come to say to you as students. Farewell, but by 
your leave I will say instead, Welcome, members of a noble profession. 
We wish you Godspeed. 

MEMOIRS. 

LESSONS IN LONGEVITY.* 

By JOHN S. CAULKINS, M. D., Thornville, Michigan. 
FIRST PAPER. 

Many physicians know that the writer of this paper is very old, and 
some know that his era dates back to 1822, the long stretch of eighty- 
three years lying behind him. From the knowledge of this fact an 
expectation has arisen that he ought to have something to say relative 
to old age which might have a modicum of value. This feeling is 
doubtless stimulated by the observation of another fact, which contem- 
plates the retention of a degree of vigor and activity (physically at 
least) perhaps somewhat greater than usually falls to the lot of those 
who reach his advanced age. Therefore, in compliance with repeated 
requests this paper has been prepared and is submitted for what it is 
worth. What is to be said on the subject will be formulated under 
these two heads : 

(i) Is it desirable to attain the age of eighty-three years? 

(2) If so, how is that objective point to be reached? 

For lack of time only the first question will be considered today, 
the second being reserved for subsequent papers. 

Is it desirable to attain the age of eighty-three years? This ques- 
tion is to be considered from two points of view — ^the personal and the 
sociological, and viewed from either the answer depends. It is the 
surroundings that must determine. Aside from the instinctive clinging 
to life, which is natural to most of the human race, a rational and dis- 
passionate view would lead one to answer this question in the negative, 
and to add that there cannot be much left to tie an octogenarian to 
earth. Youthful friends and associates have one by one gone and left 
him, and he is "a pilgrim and a stranger." Things in this world being 
so unevenly divided there is for the most want and poverty to be 
endured, while infirmities of age being many, there is pain to suffer. 
All this for the very old makes life not worth living. There are, of 
course, exceptions to this. Where a temperate and well-spent youth 

*A paper read before the Lapeer County (Michigan) Medical Society by its 
oldest member. 



246 ORIGINAL ARTICLES. 

and middle age have stored up a reserve of health and vigor ; where 
there yet remains a good degree of interest in things and events, and 
there is money enough to supply all reasonable wants, life may be quite 
enjoyable long after reaching the age at which, according to Osier's 
new gospel, persons should be chloroformed.'*' It is an old proverb that 
a man is no older than he feels. It is not the lapse of years but the 
breakdown they bring that counts. 

Examined from the other point of view, that of the community in 
which the old man lives, it will still be seen that the answer depends. 
If he can yet perform some useful work better than younger men he 
will of course be tolerated, and even if his usefulness is over, if he has 
money enough to pay his way he will be accorded tolerance ; but if he 
is helpless, and poor, too, very little interest is manifested towards him, 
however useful he may have been in his youth and manhood. Society 
is as ruthless in this humanitarian age regarding the treatment of the 
infirm old as it was in the stone age, when the custom prevailed of 
killing such as could no longer take care of themselves. That indeed 
looks cruel to us and we are apt to shudder at such barbarity, but a little 
reflection will demonstrate that it was not invariably, and probably not 
generally, barbarity which caused the act, but that a stem necessity of 
the savage state compelled it, and sometimes made the apparently mer- 
ciless procedure one of the greatest humanity possible. Suppose a case 
where winter was at hand and provisions were scarce. The tribe must 
migrate and find some place where hunting and fishing are better, and 
the long journey must be made on foot. What must be done with the 
lame, sick, and bedridden? The choice lies between leaving them to 
die of hunger or to the still more horrible fate of being eaten alive by 
wolves, or giving them the "happy dispatch." Certainly humanity dic- 
tates the latter, and the victim himself having always anticipated the 
inevitable end, unless war or accident intervened, and having served 
his father the same way, would invoke his barbarian fortitude and 
willingly submit to his fate. 

Methods vary but results are about the same in every age. The 
primitive method has much to recommend it. It is quick and easy. One 
bounce on the head with a big stick in muscular hands,' one sharp, short 
pain, one quiver and the old grandfather was off to the happy hunting 
grounds, and the bread he would have eaten helps to feed the grand- 
children through the winter. 

We no longer use the club or any similar instrument to "shuffle 
off" incapables, but we confine them in houses, generally unsanitary, 
where the minimum amount of care and comfort is found and let them 

'^This allusion to Osier is, like what he himself said in his valedictory at 
Johns Hopkins, merely jocular. Perhaps no little, casual utterance ever made 
such a commotion in a community as that. Every magazine and paper has had 
its fling at it and its author, and most of them have made the mistake of taking 
him seriously. That he was very wrong in the assertion will be shown further 
on, some good having been done, with the most far>reaching good results, after 
seventy and eighty were past 



LESSONS IN LONGEVITY. 247 

live as long as they can. Very little interest is felt in them and they 
are not missed when dead. In our present imperfect state of human 
society we cannot look for anything else. It is the law of Nature that 
whatever is born must grow old and die, and the law is necessary and 
beneficent, for otherwise the earth would become overcrowded and 
unable to support its inhabitants. The unavoidable conclusion follows 
that the old must give place to the young, since the natural rights of 
every human being are equal. The old have had their turn, and it is 
proper that they should not stand in the way of those who come after 
them. Since this is so, it is not strange that many who have the care 
of the very old grow indifferent to their want of comfort, and look at 
them as a burden of which they would gladly be rid. This indifference 
is not unfrequently felt by its victims so acutely that a resort to suicide 
is the only way to escape from the intolerable condition. 

Concluding this part of our discussion we repeat what was said at 
the outset, that the answer to the query, "Is it desirable to live eighty- 
three years?" is dependent on the surroundings of each individual, 
adding the remark that probably with the most of those who reach that 
advanced age it is wholly undesirable. 

We will now discontinue the discussion in this pessimistic way, and 
from a wider point of view look at it as applicable to the whole human 
family, and restate the question like this : "Is it desirable that the aver- 
age duration of human life on our planet should be made longer than 
it now is ?" Stated this way the unanimous answer will be in the affirm- 
ative, and we may add that it is not only desirable but necessary and 
indispensable if the world is ever to be rid of the evils by which it at 
present is infested. Ignorance is the evil and the mother of evils. Her 
children are poverty, crime,' war, and pestilence, and there is mutual 
reaction between them tending to enlarge the circle of malign influence 
of which each is the center. There is a remedy for every evil caused by 
ignorance. This none can be stupid or inconsequent 'enough to deny. 
The remedy is the discovery of scientific truth and its application to the 
affairs of men : the discovery of the true laws of Nature and obedience 
to them, whether physical, mental or moral. Truth is in her well and 
must be hunted for and drawn from its recesses. This needs time, 
which we do not have in our short term of life — our three score years 
and ten. The years for doing good work are too few. We must stop 
and die before our plans are half executed. The time for study being 
so limited progress is slow. Some say that nothing of real value is 
performed after sixty is reached. There is reason to believe this limit 
an underestimate, but we must admit that the time is very short at the 
best. There is a great loss where one man has to take up the unfinished 
work of another. He cannot begin right where the other left off, but 
must go through all the preliminary work that his predecessor has 
already mastered. It is a great waste and, besides, not very safe. 
Youth is available in adventuring into new paths and noting new facts, 



£i8 ORIGINAL ARTICLES. 

but is too volatile, self-conceited, quarrelsome and vindictive to do 
anything but one-sided work. The effervescence and querulousness of 
youth must subside and be replaced by the calm modesty of the sage 
and philosopher who has burned the midnight oil in his search for the 
truth till it stands irrefutable and apparent to every inquirer. 

Suppose the short working period doubled. It would far more than 
double our product. Instead of our present slow progress the potential 
of human endeavor would increase in geometrical proportion. When 
the time arrives that the octogenarian, instead of being counted as at 
present, hardly belonging to the living, but looked askance at as merely 
a wreck or derelict on the ocean of time, will be, as the Germans say, 
in his best years, then this earth will be a good place in which to live out 
a long lite. The remedies for poverty and crime will be found, wars 
will cease and be replaced by arbitration, and the cause of every disease 
will be hunted down and stamped out, old age included, which, accord- 
ing to the discoveries of Metschnikoff is, like the most of human ills, 
a microbic disease and can no doubt like the rest be avoided. 

It has been truly said that no chain is stronger than its weakest 
link. But why have a weak link in the chain. Let the smith look to his 
work and make every link out of the same flawless iron and every weld 
perfect and then there would be no break anywhere, the chain would 
hold all the team could draw, and all would wear out together, like the 
''one boss shay." Lives are the links in the chain of human existence, 
and although most of these links are very weak there are now and then 
notable exceptions that have grown up with sufficient cellular stability 
to outlast three or four ordinary lives. These exceptional cases have 
of course reasons and causes that account for them since every result 
is the effect of a cause, and the uniformity of Nature's laws teaches us 
that like causes produce like effects. What man has done man may do. 
It is the business of the philanthropist and philosopher to study and 
learn what these causes are as fast as possible and teach them to the 
rest of mankind. Some work has already been done along this line, 
more is being done, and much remains to be done. 

It is to be expected that here the pessimist will step forward to urge 
that it is Chimerical to believe that lengthening the span of human life 
can have any good influence toward lessening the sum of our ills but 
might instead prove a damage by lengthening the term of the undesir- 
able classes, the criminals, and weaklings, equally with the best. This 
is easily answered. It is equivalent to asserting that there is no human 
progress, and we know there is. The race has always followed the 
best light it had, otherwise we would still be wandering savages like our 
ancestors of the stond age. Poverty is the prolific mother of most 
crimes and they will die with their mother, and as for the weaklings 
who now mostly die in infancy, if they live to grow up, it will not be to 
propagate their own degeneracy. Among the discoveries of the future 
there will be one for the humane, easy, painless and complete steriliza- 



LESSONS IN LONGEVITY. 249 

tion of such as are not fit to propogate the species. Why should not 
man be improved by applying to him the methods that govern improve- 
ment in other animals ? It would puzzle anyone to say why not. Suppose 
this work done and the improvement of the animal Man placed on a 
sound and strictly scientific basis, what would the result show his nat- 
ural term of life to be ? The other animals have a limit at which, if 
they escape disease and violence, they die from sheer old age, their 
stock of vitality being exhausted. It is not likely that the genus homo 
is an exception to the rule. Several students of nature have treated this 
subject, basing their conclusions on comparisons between man and other 
animals relative to the ratio between the whole length of life and the 
period of certain stages of it, such as gestation, dentition, lactation, and 
growth, the last attracting the most attention. Comaro, in Italy, 
Buffon, the naturalist of France, and Hufeland of Germany have writ- 
ten on this subject, the latter the most elaborately. His book, "Macro- 
biotik," has been translated into all the European languages and into 
several Asiatic. Of these three, Comaro only contends for a hundred 
years, Buffon for one hundred and forty, but Hufeland says, page 149 
(Erasmus Wilson's edition), "We may with the greatest probability 
assert, that the organization and vital power of man are able to support 
a duration and activity of two hundred years." He goes on to say, 
"This assertion acquires some weight by our finding that it agrees with 
the proportion between the time of growth and the duration of life. 
One may lay it down as a rule that an animal lives eight times as long 
as it grows. Now, man in his natural state, where the period of matur- 
ity is not hastened by art, requires full twenty-five years to attain his 
complete growth and conformation, and this proportion will give him 
an absolute age of two hundred years." Chapter V of his book (first 
part) is devoted to instances of long life, considered by countries and 
professions. He says the medical makes the poorest showing among 
the professions. In a table which he gives of the ages of distinguished 
physicians there is only one above the one hundred mark. It is the 
name of our great founder, Hippocrates. He says, page 25, "Mortality 
is greater among practical physicians than perhaps among men of any 
other profession. * * * The greatest mortality prevails during 
the first ten years of practice. * * * A physician who has luckily 
passed his time of probation may become an old man." 

This paper is quite long enough for the first of the series, and the 
discussion will be dropped now with the understanding that it shall 
be resumed later. I may as well admit that besides willingness to 
please, by complying with your repeated requests for the paper, there 
was a little "motif" of my own hidden behind its preparation, and 
here it is. You remember Robbie Burns' lines: 

"O wad some power the giftie gie us, 
To see oursel as ithers see us. 
It wad frae mony a blunder free us 
And foolish notion." 



250 ORIGINAL ARTICLES. 

It goes without saying that the old man is not in so good condition 
to sec "himsel" as "ithers" see him as a young man would be, and as he 
comes nearer to the jumping-oflF place he gets less and less fit for the 
effort. It is not prudent to skate too far out on the ice of which one 
does not know the strength and thickness: better stop and see if it is 
safe for fear one will come to grief in the cold water. There is a 
stopping place somewhere just ahead and sometime everyone will find 
it, and how is the old man to know, since he cannot see for himself, 
when he has reached the spot. Evidently there is no way but to make 
a little trial and watch the result. This paper is an effort in that direc- 
tion. If an unfavora))le impression has been created, serve the writer 
as the old Romans did their wounded and inefficient gladiators, — ^tum 
down your thumbs and put him out of his misery. 

[to BB COMTINVBD.] 



EXPERIENCE WITH STATIC ELECTRICITY.* 
By NEIL A. GATES. M. D., Dexter, Michigan. 

It is not my intention to delve into ancient history and dilate on the 
antiquity of static electricity as a factor in the treatment of disease con- 
ditions, but simply to report a few cases from an experience extending 
over the past seven years, and endeavor to demonstrate that this thera- 
peutic agent is not to be regarded with indifference by the general practi- 
tioner. It may not, however, be amiss to say that from the year 1750, 
when it was first introduced into medicine, it has made rapid strides in 
advancement, until in the year 1905, when by being the best electrical 
means of exciting a vacuum tube for jr-ray work, it has become not an 
expensive luxury but an absolute necessity, and even the humblest of 
practitioners cannot afford to be without its valuable aid. It is a means 
which we should all employ rather than relinquish to the practice of 
specialists. The startling results achieved with electricity in relieving 
aches and pains and in the treatment of a large proportion of nerv- 
ous ailments due to our strenuous and unnatural mode of life, render 
the static machine an important acquisition to the armamentarium of the 
successful physician. 

In this paper, owing to lack of time, I will confine my remarks to 
the treatment of disease conditions by static electricity alone, although 
I am well aware that since its entrance into the interesting and wonder- 
ful field of jr-ray work its past usefulness seems to have been over- 
shadowed and left in the hands of a few. To be successful, there are 
some duties we owe to our machine and many points we must always 
bear in mind. 

We must have a reliable machine, large enough to obtain good 
results. A great percentage of those who have tried static electricity 
and reaped disappointment must ascribe failure to small and cheap 
machines. There are many firms now making machines which, 

*Read before the Washtenaw County (Ann Arbor) Medical Society. 



STATIC ELECTRICITY. 261 

although they present a fine appearance in the office, are practically 
worthless, for, by reason of cheap construction, they will not work in 
all conditions of weather and soon wear out even under the most favor- 
able treatment. I can readily see how a brother practitioner, having 
obtained one of these machines, soon becomes discouraged and con- 
vinced that the usefulness of static electricity is confined to the good 
impression a patient receives by being treated with so large and for- 
midable an apparatus. That this is erroneous, and that static electricity 
penetrates to the deeper organs and cures, not by hypnotizing, but by 
relieving inflammatory conditions, I shall endeavor to prove. 

To get the best results one must have a suitable room and sur- 
roundings, generally the more room around the platform the better, 
and, most essential of all, two good ground wires. With a modem 
machine, given a little attention each day, one can use it with the best 
of results every day in the year. 

Physicians must study patients. We all know that electricity of any 
kind is very disagreeable to some patients, but by carefully giving a 
short treatment with static insulation, and then following with the 
static breeze, demonstrating that the patient is not to be subjected to 
sudden shocks, the benefit derived will soon convince each that he is 
on the road to health, and the operator will be surprised to learn that 
these timid patients soon withstand a long spark and even insist upon 
having it, the relief from pain being so great that any inconvenience 
for the moment is soon forgotten. One will learn that a patient will 
readily take treatment when he finds that it is unnecessary to remove 
any part of his clothing. Think of the saving of time to a busy prac- 
titioner when a patient comes from the street and without delay steps 
upon the platform, receives treatment and departs without removing 
and replacing wearing apparel. 

One must also lake into consideration the material of the patient's 
clothing, whether woolen or cotton, and remember where pins and 
steels are likely to be concealed. In giving treatments one must always 
exercise the greatest care not to unnecessarily alarm the patient by 
accidentally touching him or placing him too near objects in the room. 
This is especially true if the patient is dressed with woolen clothes. 

A great many operators recognize no difference between the posi- 
tive and negative poles of the machine. This is a great mistake, for 
the positive pole acts as a stimulant and the negative as a sedative. 
This refers to general electrification only, for in the employment of 
the breeze and spark the reverse is true. A physician can readily see 
that he must understand the condition of the patient as well as the 
machine, and I will add that the better one attends to these details the 
better will be the result. 

Without consuming more time in explaining the diflferent forms 
of treatment, I will, by reporting the history of a few selected cases, 
endeavor to show the various forms of treatment I adopt in different 



252 ORIGINAL ARTICLES. 

cases and the startling results I obtain, which, I am sure, all practi- 
tioners will agree could not be attained with drugs. 

Case I. — A tailor, age thirty-six. From the effects of overwork 
patient was nervous, run down, and troubled with insomnia, having 
severe headaches and nausea. One night after a hard day's work over 
a gas-heated iron, the fumes from which were overpowering, this man 
closed his shop, being unable to work longer. He came into my office 
and after a careful examination I placed him on the platform con- 
nected to the negative pole of the machine, grounded the positive pole, 
and to this attached a brass-pointed electrode. I then started the 
machine and slowly moved the electrode (keeping it about six inches 
from patient) up and down his back, over his head, and finally down 
in front of him, letting it come to a stop in such a manner that I could 
get a strong breeze over the region of his stomach. I continued this 
treatment ten minutes. The patient then left the office, opened his 
shop, and worked three more hours without any discomfort. Pursuing- 
this case I gave patient daily treatments of ten minutes each for two 
weeks, when they were discontinued, being firmly convinced that he 
had entirely recovered, and time proved the correctness of this convic- 
tion. 

Case IL — A merchant came to me complaining of insomnia. 
Patient had been subjected to considerable mental strain for the past 
six weeks owing to business difficulties. The effect was a nervous 
affliction manifesting itself in severe insomnia. A brother practitioner 
had advised a vacation with a trip to the seashore, but this was impos- 
sibe for many reasons. Physical examination disclosed nothing but 
extreme emaciation and weakness. I advised a system of potential 
alternation treatments, which allowed the patient to continue the 
administration of business affairs, an absolute necessity. Patient came 
to my office evenings after closing his store. I placed him on the plat- 
form and grounded the negative pole which was attached to the head 
crown electrode. I connected the positive pole of the machine to the 
platform and also attached it to a copper plate placed under the patient's 
feet. Before administering this treatment I either had the patient 
remove his shoes, or placed several thicknesses of paper between elec- 
trodes and soles of shoes as bare shoes coming in contact with elec- 
trodes will cause an unpleasant sensation to the feet, annoy the patient, 
and counteract the good effect of the treatment. Next I took a long 
chain connected to a separate ground wire and attached it to a brass 
ball electrode held by a holder. Then I placed the brass ball from one 
to three inches (as this case required) from the electrode connecting 
the positive pole to the platform, and started the machine, the spark 
gape between electrode and brass ball being guaged to suit the patient. 
I continued the treatment for ten minutes. The patient went home and 
had a good night's rest, sleeping, as he said, more profoundly than he 
had in a month. Patient took similar treatments nightly for three 



STATIC ELECTRICITY. 263 

weeks, when all symptoms disappeared, and he had gained four pounds 
in weight, felt free from worry, and was entirely well. I will add that 
I have used this form of treatment in many cases and consider it 
the best tonic sedative. I have often had patients enter the condition 
of sleep during the treatment, and have never experienced failure to 
cure insomnia. 

Case III. — A housewife, age thirty, mother of four children, had 
slight laceration of cervix and perineum. She complained of dragging 
pain in pelvis, backache, headache, and nervousness, the latter symp- 
tom being so pronounced that she feared loss of mind. I advised oper- 
ation for repair of cervix and perineum, which was done, but without 
improvement of condition. Patient complained more after the good 
effects of a much-needed rest, which the operation necessitated, wore 
off. I then employed the static breeze as in Case I, limiting the breeze 
more especially to pelvis, back, and head. Three weeks' treatment 
effected a cure, and now, after two years, there is no return of the 
symptoms. 

Case IV, — A lumberman, fifty years old. He suffered occasional 
attacks of lumbago for eight years. When I was called, patient had 
been confined to bed two weeks, being unable to turn over without 
assistance. His doctor had been administering salicylate of soda inter- 
nally, with counterirritants to back, and relieving pain with daily 
hypodermics of morphin. Much to the disbelief of patient's friends 
and himself I informed him that I could do nothing further for him at 
his home, but that if he could get to my office I would cure him in two 
minutes. Although the patient could not believe it possible, after strong 
urging, I induced him to consent to the transfer. A great deal of per- 
suasion was necessary to influence a man in his condition to drive one 
mile, but after placing a cot in a spring wagon and conveying the patient 
thereto, the start was finally made. It was in the fall of the year, when 
the roads were rough, and after going a few rods patient insisted on 
getting out of the vehicle, and, with the help of crutches and my assist- 
ance, walked the rest of "the journey. After a short rest I laboriously 
placed him on the platform of the machine and administered a six-inch 
positive spark, obtained by connecting the platform with the negative 
pole, grounding the positive pole, the electrode being connected to the 
ground wire. I administered the sparks with the patient standing, as 
it was impossible for him to sit. In about two minutes I discontinued 
the current and requested him to step off the platform. Much to his 
surprise and gratification he did so, and found that he could bend 
forward and place his hands upon the floor without any discomfort. 
After the patient had walked around a bit I again administered mild 
sparks for ten minutes, and I can truthfully say that during the last 
four years he has not had a symptom of lumbago. This may seem an 
exaggerated case but I can give assurance that it is not, and anybody 



254 ORIGINAL ARTICLES. 

accustomed to the moderate use of static electricity has had many 
similar experiences. 

It is needless to say that the patients this particular case has brought 
me would pay for a great many static machines. I have treated many 
cases of lumbago and other forms of muscular rheumatism, and where 
I can use a six-inch spark I never fail to give instant relief. In cases 
where the patient will not tolerate the spark the positive breeze will 
surely effect a cure, although longer time will be required. 

Case V. — A furniture dealer, age forty-two. After sustaining a 
wrench of the shoulder, followed by rheumatic pains, this man con- 
sulted me regarding a partial paralysis of his right arm. On examina- 
tion I found almost a complete atrophy of the trapezius, deltoid and 
infraspinatus muscles. I connected the patient to the machine in order 
to obtain the induced static current, using the smallest Leyden jar I 
had. Patient was requested to hold one electrode in his left hand while 
the other was placed to his shoulder outside clothing. I then started 
the machine slowly, and for five minutes caused feeble contraction and 
relaxation of these muscles; then for another five minutes turned the 
machine rapidly, using the current as a massage. This treatment was 
continued for four weeks, resulting in complete cure of the paralysis 
and restoration of muscle symmetry. 

Case VI, — An unmarried woman came to me suffering from amen- 
orrhea and accompanying symptoms which I diagnosed as chlorosis. I 
gave the patient daily treatments of positive insulation continued for 
ten minutes and accompanied by a negative breeze to the pelvis. In 
three weeks the patient was discharged well. 

Case VII. — A married woman consulted me for a badly sprained 
wrist following a fall. There was no fracture or dislocation of the 
bones. I treated the wrist daily with static breeze, with the result that 
swelling and soreness subsided within a week. 

Case VIII. — An unmarried woman sought relief from a distressing 
acne indurata. I employed the positive breeze on her face, using a 
wooden electrode. Three weeks sui&ced to effect a cure. 

In selecting these cases for report I purposely picked those in which 
no drugs were used. I would not say that this is wise in every instance, 
for I think it better in many cases to employ both. The results show, 
however, that a great deal can be accomplished with static electricity 
alone. I do not wish to impart the' impression that static electricity is 
a cure-all, for it is not, but it can be employed, with safety, in every 
case. Nothing will relieve the pains of neuritis, nervous headache, 
and the vomiting of pregnancy so quickly as will static electricity. 

In closing I will add the assurance that from my own experience, 
after a hard day's work, nothing is more refreshing and invigorating 
than ten minutes application of the static breeze. Try it. 



CLINICAL SOCIETY 265 

TRANSACTIONS. 



CLINICAL SOCIETY OP THE UNIVERSITY OP MICHIQAN. 

STATED MEETING, JANUARY 15, 1906. 

The President, WILLIAM K. LYMAN, M. D., in the Chair. 

Reported by DAVID M. KANE, M. D., Secretary.^ 

REPORT OF CASES. 

ADENOIDS, 

Doctor William R. Lyman : I do not intend to discuss the sub- 
ject of adenoids fully, but rather to report some observations based 
upon a study of the records of the Otolaryngologic clinic at the Uni- 
versity Hospital for the year 1905 ; to compare them briefly with our 
accepted opinions; to call attention to the frequency with which this 
disease is accompanied by serious complications and to emphasize the 
importance of early treatment. 

During the year 1905 there were examined one hundred and forty- 
five cases of adenoids, of which number seventy-nine also had chronic 
hypertrophy of the faucial tonsils; in fact, in many cases it was the 
tonsilar condition which brought the patient to the clinic for relief. 
Many of the patients were college students, which fact is of importance 
in the interpretation of data to be brought forward later. As to sex 
there were ninety males and fifty-five females. The preponderance of 
males as compared with other statistics is explainable by the fact that 
this clinic draws largely from the student body for its material. For 
purposes of convenience the following tabulation sets forth the number 
of patients per semidecade : 

From 1-5 years old 9 From 5-10 years old 39 

From 10-15 years old 31 From 15-20 years old 21 

From 20-25 years old 31 From 25-30 years old 8 

Over 30 years old 6 

One is at once struck by the small number of cases found in the first 
semidecade of life, during which period we are informed the greatest 
number of patients present themselves to our observation. The great- 
est number of any single semidecade was that between the ages of five 
and ten. Fully thirty-six per cent of our cases occurred between the 
ages of fifteen and twenty-five. One case was that of an adult fifty- 
seven years old. These figures are quite at variance with those ordi- 
narily set forth, but the fact admits of ready explanation. The pres- 
ence of nasopharyngeal abnormalities is often overlooked by the 
parents. The significance of adenoids in children is not widely or fully 
appreciated and a large per cent of the patients of this clinic were Uni- 
versity students, which latter fact alone accounts for the variation. 

Of importance is the time of year during which the greatest number 
of patients presented themselves for treatment. The records for April 



256 ORIGINAL ARTICLES. 

and May show an enrollment of thirty-five cases, which suggest the 
relationship of adenoids to the nasopharyngeal disturbances so 
frequent in early spring. The patients in general complained of 
the classical symptoms of the condition— difficult nasal re^iration, 
mouth-breathing with its characteristic facial expression, and, to 
quote Doctor Schadle, "The open mouth, the pinched nose, the 
drawn down inner canthi, elevated eyebrows, corrugated skin of the 
forehead, the distorted chest, the altered voice, the apparent defective 
development — ^both mental and physical." There may be added : pro- 
truding upper teeth, and high palatal arch; repeated attacks of sore 
throat, which is generally due to the associated tonsilar hypertrophy ; 
a fullness and the sensation described as something dropping in the 
back of the throat ; a seromucoid discharge from the nostrils ; the state- 
ment of the parent that the child is apparently aflFected with a continu- 
ous cold in the head ; a voice thick aq^ without resonance, such letters 
as m and n not being pronounceable ; and, frequently, palpability of the 
submaxillary and cervical lymph glands. 

Adenoids are characterized by the occurrence of complications 
directly due to the condition. Among those most prominently met 
were the following : Deafness of varying degree in sixty-five patients, 
some complaining of only slight stuffiness of the ears and occasional 
tennitus, both of which conditions were more marked when the patient 
had a cold. Many could hear the whispered voice, if at all, only a 
fraction of the normal distance, which is twenty-one feet. There were 
about thirty patients who had discharging ears at the time of examina- 
tion, and many more cases in which the examination showed evidences 
of previous suppuration. The presence of adenoids was a marked 
factor in the susceptibility to the acute infectious disease, particularly 
measles, scarlet fever, and whooping-cough ; repeated attacks of tonsil- 
litis, pharyngitis, and acute rhinitis, the patients taking cold at the least 
exposure ; a constant dry, hacking cough ; gastrointestinal disturbances, 
manifested by a rapacious appetite and alternating constipation and 
diarrhea; retarded mental development, many of the children being 
several grades less advanced in school than normal children of similar 
ages; while several cases showed defective development of the chest, 
resulting in pigeon-breast. 

The treatment has been complete removal of the growth, this being 
done under primary ether anesthesia with the patient in the sitting 
position. The instruments used were the adenoid forceps, Mthen the 
tissue was abundant, followed by the Beckmann curet, and all small 
portions remaining were removed with the finger. 

The results have been without exception favorable. There has been 
no case of hemorrhage. Those cases accompanied by ear complications 
have been very satisfactory both as to the improvement in hearing and 
the cessation of the discharge. The improvement in the general con- 
dition was very noticable, and this was especially true in the young 
patients. 



ANN ARBOR MEDICAL CLUB. 267 

Among the reasons for the removal of adenoid vegetations may be 
mentioned : The prevention of pathological conditions of the ears and 
the beneficial effect upon the ear complications; the establishment of 
free nasal respiration, thus doing away with mouth-breathing and its 
attendant disadvantages; the marked and rapid improvement in the 
patient's general health. The last two conditions were much more 
striking in the young patients. The removal of a constant source of 
infection, statistics showing that one case in five have tubercle bacilli 
either in the substance of the growth or upon its surface, and, as already 
mentioned, the presence of adenoids increases the susceptibility of the 
patients to the acute exanthemata. 

The dangers of the operation, if correctly performed, are very slight 
and the beneficial results as marked as those derived from any operation. 



ANN ARBOR MEDICAL CLUB. 

STATED MEETING, APRIL i8, 1906. 

The President, JOHN A. WESSINGER, M. D., in the Chair. 

Reported by JOHN WILLIAM KEATING, M. D., Secretary. 

REPORTS OF CASES. 

RETENTION OF URINE. 

Doctor Cyrenus G. Darling : I wish to report two cases to show 
some methods of treating retention of urine. A man, seventy-five years 
old, had been using a catheter for five years because of enlarged prostate 
and cystitis. One day he was unable to pass the soft rubber catheter 
that he was accustomed to employ, and attempted to insert an old one 
which had been about the house for some time, because it was smaller. 
The tip had already been broken oflF. He not only failed in the attempt 
at satisfactory insertion but when he tried to withdraw the instrument it 
broke, leaving a piece of unknown length in the bladder. To still further 
complicate matters he threw the withdrawn fragment into the fire. He 
then called his physician who secured three fragments of catheter, prob- 
ably all that had not been previously removed ; still the physician was not 
able to gain acress to the bladder because of the injury which the patient 
inflicted upon himself. I saw patient about thirty-six hours later, 
when I found the bladder enormously distended because no urine had 
been passed. The pulse was weak and he presented all the signs of a 
septic condition. I decided to drain the bladder but patient was in no 
condition to take an anesthetic. I then made a suprapubic incision 
under local anesthesia (Schleich's solution). A large amount of very 
offensive urine was allowed to flow slowly away, and the patient was 
immediately relieved but was already so septic that he did not improve. 
He became gradually weaker and died on the following day. The second 
case was that of a boy eight years old who fell astride of a stick, com- 
pletely severing the urethra. This was followed by infiltration of the 
perineal tissues and retention of urine. The physician failed to find the 



258 ORIGINAL ARTICLES. 

opening of the torn urethra and reached the bladder by puncturing with 
a trochar through the perineuni along the supposed line of the urethra, 
and introducing a tube for the purpose of forming a new urethra. After 
the tube was removed the new urethra remained for some weeks, but 
gradually contracted until no urine could be passed except by drops. 
Patient was brought to the University Hospital in this condition. For 
immediate relief suprapubic puncture was employed. The following 
day I attempted to find the end of the torn urethra by a perineal incision, 
but failed. I was obliged to resort to retrograde catheterization by 
incising the bladder, finding the urethral opening and introducing a 
catheter into it. This was carried anteriorly until the tip could be felt in 
the perineum, where the end was exposed by an incision. The other 
end was treated in. the same way. Because of a large amount of cica- 
tricial tissue no attempt was made to suture the ends but an English 
catheter was placed in the canal and kept there for a few days until the 
ends were approximately united. The wound in the bladder was closed. 
The patient left the hospital with a good urethra. When the catheter 
fails, retention of urine may sometimes be relieved by putting the patient 
in a warm bath, by using a general anesthetic to relax spasm, or by supra- 
pubic puncture or incision. These latter may frequently be employed 
when a general anesthetic would not be safe. Incision should be made 
when it is necessary to drain the bladder. The use of Schleich's solution 
completely anesthetizes all of the tissues except the bladder wall. This 
is opened with a single, rapid incision. Puncture is so easily and safely 
performed that there are but few reasons why it may not be employed. 
Retention must always receive prompt treatment when cystitis is present 
or more serious ccmditions may follow, as in the first case reported. 
Retention from rupture of the urethra is treated by early perineal 
incision, with suturing of the torn ends, or holding in place by catheter 
as mentioned in the second case. 

AN UNCOMMON FRACTURE, 

Doctor Ira D. Loree: This fracture is not uncommon from the 
fact that it does not occur frequently but because it is not often diag- 
nosed. In the past fracture of the carpal bones has, no doubt, many 
times been overlooked, but with the great advantages offered by the 
radiograph the true nature of many wrist sprains is coming to light. 
This patient was sent to me by Doctor Yutzy. His accident hap- 
pened while scuffling, which resulted in a fall and striking upon his 
hand. Whether or not he fell upon it in a way to produce flexion or 
extension he could not tell. The seat of injury was too far forward to 
be a Colles' fracture, and while deformity and crepitus were absent, 
there was too much pain, and swelling in the soft parts, not to interpret 
a broken bone. The radiographs which I pass around readily reveal 
the seat of difficulty in the os magnum and scaphoid. To properly diag- 
nose this condition both wrists should be photographed, as sesamoid 
bones may be mistaken for fracture. 



FAT INDIGESTION IN INFANTS. 259 

ORIGINAL ABSTRACTS. 



SURGERY. 

By FRANK BANGHART WALKER, Ph. B., M. D.. Detroit. Michigan. 
movassoK of sukgut amo opbkativb sukgbrt in tub dbtkoit potTGKADUATS SCHOOL or mboicimb: 

ADJUNCT FftOPBSSOB OF OPBBATIVB SOBGBBT IK THB DBTBOIT COC.LBCB OF MBOICINB. 

AND 

CYRENUS GARRITT DARLING, M. D., Ann Arbor, Michigan. 

CUMICAL PBOFBSSOB OF SVKGBBT IM THB UMIVBBSITT OF MICHIOAM. 



MORTALITY AFTER PROSTATECTOMY. 
In Jcma, Volume XLVI, Number XIX, Tenney and Chase give 
some interesting observations on the results of prostatectomy. Age of 
itself, they state, is no argument against the operation, but their figures 
show better than any amount of argument the desirability of early oper- 
ation. The convalescence of elder patients was in marked contrast to 
that of the younger patients. In studying seventy-three deaths fatal 
periods were noticed. There were twenty-three deaths, or more fatali- 
ties in the first forty-eight hours than in any other two days. Another 
period of mortality includes the seventh, eighth and ninth days, which 
showed twelve deaths. On the thirteenth and two following days there 
were six deaths, and on the twentieth to twenty-second days inclusive, 
there were seven deaths. Two-thirds of all the deaths came during 
these fatal periods. Contrary to statements by MouUin, Richardson 
and others that patients with stone in the bladder are more favorable 
subjects for operation than others, their list contains one hundred seven 
cases complicated by vesical calculus with a mortality of thirteen or 
twelve per cent, as compared with 8.6 per cent mortality among the 
cases without stone. The inferences drawn from a comparison of mor- 
talities with ages were that the older men are less likely to stand the 
shock and loss of blood in the operation, and that the younger men 
stand the sepsis, uremic complications and confinement less well than 
the elders. Believing that the result is not so much a problem of speed 
or technic in the operation, they lay great stress upon the preparation 
of the patient, the anesthesia, and the careful and intelligent attention 
almost constantly during the first forty-eight hours, and the same sort 
of attention later at frequent intervals until his convelescence is well 
established. f. b. w. 



PEDIATRICS. 

By ARTHUR DAVID HOLMES, M. D.,C. M., Detroit, Michigan. 



FAT INDIGESTION IN INFANTS. 

LowENBURG {Medical Bulletin, November, 1905) says that an 

excess of fat may not infrequently be a source of indigestion. Infants 

thus fed vomit from half to an hour after feeding. The vomited 

material has an odor of butyric acid and is sour. Diarrhea is a frequent 



260 ORIGINAL ABSTRACTS. 

symptom. The stools are greasy and respond to the osmic acid test 
for fat, and oil globules are seen with the microscope. The fat may 
appear in the stools as lumps not unlike those of casein. A progressive 
loss of weight is soon or late a prominent feature. The condition is 
best prevented by starting the infant on low fat percentages. The 
increase should be gradual and never reach above four per cent. In 
the active management of such a case a calomel purge should be admin- 
istered if vomiting is a permanent feature. The fat should be at once 
reduced to less than one per cent, and then only gradually and carefully 
increased, stools and condition of the stomach being carefully watched. 



TREATMENT OF ENURESIS. 
Thursfield (British Medical Journal, April 21, 1906) says that 
atropin used in the form of an extract, tincture, or as liquor atropin is 
the only drug from which he has had good results in the treatment of 
enuresis. He recommends ten minims of the tincture three times a day 
as an initial dose, and increases the amount week by week until the 
dose produces evidences of its action. It should be used over a long 
period, usually from three to six months, for permanent relief. The 
dose should be diminished gradually until it can be left off with safety. 
He also recommends the use of potassium citrate in conjunction with 
belladonna in the majority of cases, and in some cases where hyper- 
acidity of the urine was the cause, he found the administration of 
potassium citrate alone very efficacious. He also speaks highly of 
urotropin well diluted. 

TREATMENT OF CEREBROSPINAL MENINGITIS. 
Osborne (New York Medical Record, February 17, 1906) says, 
regarding the treatment of this affection, that it consists in diminishing 
the congestion, in preventing or relieving the spinal or cerebral pres- 
sure, and in combatting the acute symptoms and complications as they 
arise. He says further that the administration of diphtheria antitoxin 
in this affection is theoretically unsound and practically a failure. Spinal 
puncture is of benefit in some instances for the relief of pressure, but 
only in rare instances, he believes, is it indicated for diagnostic pur- 
poses. The sore throat should be treated with antiseptic gargles and 
sprays, and the conjunctivitis with solution of boric acid. If the pain 
is not severe and the pulse good, bromides or chloral may be given ; 
otherwise treat by wrapping the painful joints with cotton, applying 
heat, giving a calomel or saline purge, and administering morphin. 
The author believes that to quiet the cerebral excitement and delirium 
and to intensify the action of the morphin in these cases the adminis- 
tration of ergot intramuscularly or subcutaneously at six-hour intervals 
gives good results. The ice-cap and the spinal ice-bag are necessary, 
and if the temperature is subnormal or the surface of the body is cold, 
dry hot applications are of advantage. He is convinced that ice, ergot, 
and morphin will save many patients from death by this disease. 



TUBERCULOUS OSTEITIS OF KNEE. 

ORTHOPEDICS. 

ait IRA DEAN LOa^ Iil^D., Ann Arbor, Michigan. 

sum ASHITAKX IH. SypMSjMX I|t.TBB DMXTOaiTY OV mCMIGAM. 



261 



EARLY OPERATIVE TREATMENT OF TUBERCULOUS 
OSTEITIS OF THE KNEE. 

Bernard B/sblow, M. D., oi. QMffalo^ in the American Journal of 
Orthopedic Surgery for Aprit 19P6. His report. Qonfioes, itself to three 
cases in which the focus of disea^ had not reached the jcHnt, but wa3 
confined to the end of the femur. He advisee excision of the diseased 
bone, and, if there has been prolonged contraction, division of the 
ham-string tendons. ' 

The histories of the two patieato which he presents a^re to substan- 
tiate his previously reported resulte. in this tine o{ workv 

The first patient was a girl, niw years old, with flexion posture of 
forty-five degrees and a range of free movement of fifteen degrees. 
There was. much enlargement of th^ inner condyle (Figure I) with pajja 
at this point upon digital pressure. The tibia wa^ partially subluxated 




First Patient — Figure I. 



First Patient— Figure II. 



with abduction and some rotation outward. She had passed the stage 
of muscular spasm and night cry. After thoroughly cleaning out the 
area of disease the cavity was swabbed with a five-per-cent formalin 
solution, aft^r which the periosteum and skin were repaired. A plaster- 
of- Paris splint was applied as shown (Figure II). After four weeks 
the condition present was as indicated in Figure III. Figure IV shows 
the amount of flexion obtained after twelve months. Genu valgum 



1 



262 



ORIGINAL ABSTRACTS. 




First Patient — Figure III. 



First Patient — Figure IV. 





First Patient -Figure V. 



First Patient — Figure VI. 



TUBERCULOUS OSTEITIS OF KNEE. 



263 



developed later as shown in Figure V. There was no return of the 
tubercular process, however, and the former condition was corrected by 
osteotomy, with results shown in Figure VI. 

The second patient was a boy, three years of age. Disease had 





Second Patient— Figure VII. Second Patient— Figure VIII. 

progressed for three months when first seen. The joint had a typical 
posture with its enlarged inner condyle, night cry and pain through the 
day, with morning lameness. There was flexion posture of twenty 
degrees with very slight free movement. Treatment was the same as 




Second Patient — Figure IX. 
before. It was necessary here to penetrate healthy epiphyseal tissue. 
Massage and passive motion were employed after the sixth week. 
Figures II and III show the joint eleven months after the operation 
with posture, growth and range of motion normal. 



864 ORIGINAL ABSTRACTS. 

OPHTHALMOLOGY. 

' By WALTER ROBERT PARKER, B. S., M. O. 
rmowwMom ov onrrHAUiouwv m tub uwnMin r of michioam. 



EXPERIMENTAL INVESTIGATIONS ON THE INFECTION 
OF CORNEAL WOUNDS BY SALIVA. 

HocTA (Kim. MonaisbL fur AugenkmOhmde, September, 1905) 
has ftnmd that saliva may be brought iit omtact with corneail wounds 
by means of objects contaminated with saliva, sudt as fiigers. and 
handcercbiefs, or drops of saliva may come fhim the iterator's miMUli. 

The writer's experiments were partly to determine (a) what organ- 
isms in the saliva, when in contact with a^ newly-made corneal wound, 
are most likely to produce a purulent ker^itis, and (b) what forait of 
wound, exposed to the microorganisms of the saliva, is most likely to 
give rise to purulent inflammation. 

For his experiments rabbits, cats, and mice were used. Saliva was 
obtsuned from persons of different ages and positions. The lids were 
everted and the eye washed with 0.05 per cent sublimate lotion, then 
witii physiologic saline solution. 

A wound was made in the cornea : 

(aa) Nonperf orating. 

(i) An abrasion by scratching the surface of the cornea with 

the point of a needle. 
(2) A pocket, a wound made by a keratome between the corneal 
lamellae. 

(bb) Perforating wounds made by a Graefe knife. 

Saliva taken from a sterile Petrie dish, by means of a sterilized 
spatula, was carefully rubbed on the wound, or inserted into the pocket. 
In the case of perforating wounds care was taken not to introduce the 
spatula into the anterior chamber. 

After twenty-four hours a cover-glass preparation and a culture 
were made from the secretion of the wound. The media used were 
neutral agar, glycerine agar, Loeffler's blood serum, and bouillon. All 
media were placed in an oven at 35° centigrade. 

Results of ninety experiments : 

(a) Always negative in thirty perforating wounds. 

(b) Once positive in diirty abrasions. 

(c) Always positive in thirty pocket wounds. In most of these 
cases there was iritis, hypopyon, marked circumcomeal injection and 
conjunctivitis. 

In these thirty cases pneumococci were found eleven times (thirty-six 
per cent) ; streptococci seventeen times (fifty-six per cent) ; staphy- 
lococci nine times (thirty per cent) ; tetragenus was also seen five times. 
In six of the cases no culture was obtained. 



CANCER OF THE LARYNX. 966 

Infectioii of operation wounds by drops of saliva from the operator : 
Hotta performed experiments similar to those of Hubener, but modi- 
fied them in view of the special conditions present in eye operations. 
He found that a veil of doubled muslin does not absolutely prevent the 
spraying of the saliva. But he believes that in eye operations this is 
certainly sufficient to prevent infection from the mouth. The possi- 
bility of infection from the saliva during the operation cannot be abso- 
lutely denied, yet.it must be so rare that in eye operations in general 
a special measure to prevent it does not seem necessary. 



LARYNGOLOGY. 

By WILLIS SIDNEY ANDERSON, M. D., Detroit, Michigan. 

ASSISTANT TO THB CMAIE ^F LABYNOOLOOT IN THB DBTROIT COLLBOB OF MBDICINB. 



REMARKS ON THE MACROSCOPIC DIAGNOSIS AND GEN- 
ERAL INDICATIONS FOR TREATMENT OF 
CANCER OF THE LARYNX. 

Doctor John Noland Mackenzie (Annals of Otology, Rhinology 
and Laryngology, March, 1906) makes some positive statements in 
regard to this much dreaded disease. He states that in the present 
state of our knowledge there are three principal methods of diagnosis 
in laryngeal cancer : 

(i) The naked eye method, or diagnosis by direct inspection, sup- 
plemented by clinical phenomena. 

(2) Thyrotomy. 

(3) The microscope. 

Take it all in all, the first method is the most practicable and satis- 
factory of the three. The author insists very strongly on the applica- 
tion of the naked eye method of diagnosis in the case of malignant 
tumors of the larynx. Every recourse and refinement of clinical diag- 
nosis, including the exclusion of S3rphilis by the iodides, and tubercu^ 
losis by tuberculin, should be resorted to before appeal to the micro- 
scope is made. By following the lead of the general surgeon, with the 
means of clinical diagnosis at our command, together with the more 
exact information concerning the naked eye appearances of the cut 
surface of laryngeal neoplasms, we will soon be in a position where we 
will be more and more independent of the pure pathologist for help in 
diagnosis. 

The objections urged against the indiscriminate removal of tissue 
for examination, especially when done through the natural passages, 
are as follows : 

(i) It subjects the patient to the danger of autoinfection at the 
point of incision and to metastasis elsewhere. 

(2) It stimulates the local growth of the cancer. 



266 ORIGINAL ABSTRACTS. 

(3) Finally, the method is often inconclusive, misleading, and some- 
times practically impossible. 

In practically all cases of laryngeal cancer, death is due to metas* 
tasis. In neighboring organs (the neck and mouth) metastasis takes 
place with certainty and at an early date. It is, therefore, probable 
that the glands of the neck are affected in cancer of the larynx, although 
perhaps not recognizable by the senses of sight and touch, at a much 
earlier period than is generally supposed. It is at all events safer to 
assume this to be the fact than to accept the statement, unsupported by 
definite anatomical proof, that cancer in the interior of the larynx 
remains for a more or less indefinite period as a purely localized disease, 
and does not get into the lympathics of the neck until a late stage of the 
affection. 

The author is very much opposed to intralaryngeal operation, and, 
in a general way, is pessimistic in regard to the permanent cure by 
surgical measures, although advocating the thorough removal of the 
growth if seen in the earlier stages. 



PROCTOLOGY. 

By LOUIS JACOB HIRSCHMAN, M. D., Detroit, Michigan. 

CUNICAL PROFUaOB OV PROCTOtjOGT IM TUB DBTmOlT COLLSCB OV BCBDICXMB. 



LOCAL AND REGIONAL ANESTHESIA IN RECTAL 

SURGERY. 

Cooke (Janta, Volume XLVI, Number XXII) states that in the 
last twenty months he has employed local anesthesia in seventy cases of 
rectal and anal surgery comprising thirty-eight cases of internal hemor- 
rhoids, two of prolapsus ani, five of fistula, nine of fissure, and sixteen 
of external hemorrhoids. 

Pressure anesthesia by means of injections of sterile water or weak 
solutions of anesthetic drugs, was employed in all cases. For fissure 
and external hemorrhoids, 0.25 to 0.5 per cent beta-eucain solutions 
were used to anesthetize the integument in preference to sterile water 
anesthesia. From personal experience Cooke feels warranted in claim- 
ing for local anesthesia in rectal surgery, the following advantages : 

( 1 ) It is simple, safe and effective. 

(2) It eliminates the dangers and discomforts of general anesthesia. 

(3) Pain at the time of operation is usually absent and always so 
slight as to be easily borne. 

(4) Postoperative pain is less by far than after the old methods. 

(5) Time required for the operation is greatly reduced. 

(6) Confinement to bed is rendered a matter of expedience, rather 
than necessity. 

(7) The period of detention from business is diminished fully one- 
half. 



MERALGIA PARESTHETICA. 267 

(8) Under this method the hospital becomes a convenience and 
luxury rather than a dreaded essential. 

(9) It is a thoroughly reliable means of affording relief in many 
cases which would otherwise be unsuitable for operation. 

( 10) It robs these operations of their terrors and makes it possible 
to reclaim this work from the hands of the "no knife" advertisers. 



DERMATOLOGY. 

By WILLIAM FLEMING BREAKEV. M. D., Ann Arbor, Michigan. 

CUmCAL FItOPnSOB OP DBKMATOLOGT AlffD STFMILOLOGT IK THE UmVnSITT OT MICHIGAN. 

AND 

JAMES FLEMING BREAKEY, M. D., Ann Arbor, Michigan. 

ASSISTANT IN DBKICATOLOGT IN TMB UNIVBHSTTV OF MICHIGAN. 



"A NOTE ON THE TREATMENT OF SIMPLE WARTS BY 
INTERNAL REMEDIES," , 

Under this titk Arthur Hall refers (British Journal of Dermatol- 
ogy, March, 1906) to a case previously reported by him in which 
numerous warts of the scalp, of two years duration, disappeared in two 
to three weeks' time under the administration of mistura alba thrice daily. 
Doctor Chalmers Watson had claimed that it was not the drug but 
the purgation which accomplished the result, and Hall now reports a 
case seeming to bear out that theory. 

A girl, age fourteen, came to his clinic almost incapacitated by 
reason of warts on wrists, hands, and fingers, she having counted three 
hundred sixty-seven on one hand and wrist alone. She had always 
been constitpated. Mistura alba (one-half ounce three times a day) 
was prescribed and used five days. The bowels still being costive the 
dose was doubled with still no improvement. After two weeks without 
change confection sulphur and confection senna (one dram of each) 
was substituted without result. Eleven days later the sulphur was 
discontinued and an aloin and nux pill prescribed. Within a week 
following this the warts began to shrink. The bowels were regular. 
The treatment was continued for about two and one-half months, 
at which time the hands and wrists were clean and but slight evidences . 
of the warts remained on the fingers. This without the use of any 
local treatment. j. f. b. 

MERALGIA PARESTHETICA. 

Doctor James C. White reports (Journal of Cutaneous Diseases, 
April, 1906) the following case as of especial interest in view of the 
fact that he has been unable to find the affection mentioned in any sys- 
tematic work on dermatology or its symptomatology referred to in 
chapters devoted to disturbances of sensation. 

The patient, a male, age fifty-five years, became aware of disturbed 



268 ORIGINAL ABSTRACTS. 

sensations in the skin of the outer lower two-thirds of the ri^^t thigh 
after his customary walk of four or five miles. The sensation was of 
a tingling nature. From this time on— either standing or walking — 
this region became the seat of a variety of perverted sensations, 
tingling) tenseness, tearing, and sometimes a dull, deep ache. These 
sensations were often usherd in by a growing sensaticxi in the part 
The disturbances usually ceased on sitting or lying but might recur in 
these attitudes from overstretching or twisting the leg. Deep pressure 
over the area might also bring on the sensations. There was always 
a sensation of something wrong on standing or walking. No pruritus 
or throbbing or feeling of constriction was noticed. The area com- 
plained of corresponded to the distribution of the cutaneous filaments 
of the external cutaneous femoral. 

Inspection of the leg showed little difference from its fellow, perhaps 
a little paler. Induced hyperemia recedes more slowly than in its 
fellow. The whole area was partially anesthetized, and over the patella 
anesthesia was complete. Deep pressure over both legs showed little 
difference in sensation. Dimensions of legs the same. Habits of 
patient good. 

Meralgia paresthetica is a condition always confined to the area 
occupied in this case. It was first described about ten years ago by 
Ben^ardt and Roth, and is described in works on nervous affections, 
but Doctor White presents it as having claims for recognition in the 
lists of cutaneous diseases. The neurologists have offered little that is 
definite as to its cause. 

Treatment is unsatisfactory, though massage gave partial and 
temporary relief. 

It has no apparent effect upon the general welfare of the patient. 

J. F. B. 



NEUROLOGY. 

By DAVID INGLIS, M. D., Detroit, Michigan. 
PROvnaoK or mmvoos amo icbmtal disbaski ik tmb dbtkoit coixacs or icBDicim. 

AND 

IRWIN HOFFMAN NEFF, M. D., Pontiac, Michigan. 

ASSISTANT PMnXCIAN AT TMB BASTBBK MICMIOAK ASTLUM. 



"TYPES IN MENTAL DISEASES." 

William A. White has an article in the Journal of Nervous and 
Mental Disease (April, 1906) on this subject. The author gives a 
rather cursory review of the insanities, following Kraeplin's grouping 
of the psychoses. He emphasizes the difficulty of differentiating some 
of these types, and calls particular attention to the transitional forms, 
deprecating the custcxn of analyzing mental diseases with a primary 
tendency to group the mental trouble. He believes that this method of 
attempting to g^oup the psychoses before a complete analysis of the 
syndrome may lead to confusion. White gives a table, dividing the 



AMERICAN MEDICAL ASSOCIATION MEETING. 209 

psychoses into two great groups— dementing and nondementing 
psychoses. These, with necessary subdivisions, form, as he believes, 
a practical working classification. In conclusion he makes the following 
summary: 

(i) The necessity for a broad biological viewpoint in considering 
the problems of mental alienation. 

(2) The inconstancy and variability of t3rpes in mental disease as 
shown by , 

(a) The occurrence of transition and intermediate forms. 

(b) The overlapping of superposition of clinical types. 

(c) The occurrence of special groups of symptoms — syndrcmies 

— ^in widely different clinical pictures. 

(3) The desirability of a pause in the universal tendency to the 
analysis of mental symptoms for the purpose of developing general 
principles under which to group results. 

(4) The suggestion that a great deal could be accomplished in this 
direction by the study of certain symptom groups apart from the special 
diseases which they more or less typify. 

(5) The illustratk)n of what can be accomplished by this method by 
its application to the dementia syndrome. i. h. n. 



EDITORIAL COMMENT. 



AMERICAN MEDICAL ASSOCIATION MEETING. 

Boston is entitled to the glory of being the scene of the banner meet 
of the American Medical Association, the unprecedented attendance of 
over five thousand having been registered at the recent gathering of 
the clans in that city. Whether the national event was the sole magnet 
that attracted this multitude, or whether the practically coincident annual 
meeting of the Massachusetts Medical Society, which contributed about 
one-fifth of the number, was the potential factor in effecting high-water 
mark on this occasion is immaterial insofar as concerns yielding the 
palm to Boston for the greatest display of lapel insignia medical since 
the inception of the national body. From the viewpoint of both scientific 
and business achievement the meeting was likewise a memorable event, 
but since the organization seems to be developing a commercial spirit 
which bids fair to completely overshadow the intent of its original 
promoters, the business aspects will be accorded preference in reviewing 
some of the more important questions that received consideration. 

4t 4t 4k 

Doctor McMurtry, in his address before the House of Delegates, 
congratulated the association on the removal of every vestige of the old 
disagreements between New York medical men and the return of the 
profession of that state as a united body. Attention was directed to the 



270 EDITORIAL COMMENT. 

dissatisfaction that prevails regarding the action of the Council of 
Pharmacy and Chemistry in excluding advertisements of certain pro- 
prietary medicines from the journal conducted by the association, the 
contention having aroused a marked degree of antagonism toward the 
supposed policy of the secretary-editor who was merely executing the 
mandates of the trustees. Indeed dissatisfaction with the management 
of the association generally has assumed such proportions that a resolu- 
tion was introduced requesting the appointment of a committee to inves- 
tigate the affairs of the secretary and treasurer, but the shortsightedness 
of zealous friends was responsible for tabling the measure and thereby 
unfortunately committing the officers to unwarranted suspicion. If The 
report of Doctor Simmons disclosed the informaticm that there were 
23*636 members in the association, 4,351 having affiliated therewith 
during the past year. ^ Doctor Happell, chairman of the Board of Trus- 
tees, reported that the association was in a flourishing condition finan- 
cially, the assets being nearly $238,000. During the past year the income 
from all sources aggregated about $275,000. The expenses for this period 
were approximately $250,000, leaving an annual income of $25,000 to 
augment the total net assets to $247,500. With an indebtedness of only 
about $10,000 the above rendering certainly justifies continuance of the 
incumbent financial management, f Doctor Reed, of the Committee on 
Medical Legislation, reported the recommendation of an appropriation 
to facilitate the formulation of a bill for the department of public health 
and the payment of current expenses of the Committee. If Doctor 
Rodman, of Philadelphia, called attention to the necessity for uniform- 
ity of license g^nting in the various commonwealths of the United 
States, and while deploring the improbability of inunediate naticmal 
control of licensiation, suggested that the Council on Medical Education 
should be empowered to issue licenses to practice medicine in any state. 
If The report of Doctor Keen, chairman of the Committee on the Walter 
Reed Monument Fund, showed that $19,700 was m hand and $1,200 in 
subscriptions outstanding. The ungratefulness of human nature is 
manifest in the fact that quarters rendered immune to yellow fever by 
the discovery of Doctor Reed ccmtributed the smallest amounts to his 
memory. If A series of resolutions endorsed the conduct of Secretary 
Simmons and disclaimed any intention on the part of the American Med- 
ical Association or the State Medical Societies to injure the independent 
medical journals owned or edited by physicians — ^the later declaration 
precipitating in face of the fact that the independent medical journals 
are confronted by a system of competition which frequently proffers 
advertising space for a pittance and invariably renders puUication 
without price. However, this is considered legitimate privilege in 
business transaction. It is likewise considered legitimate criterion in 
judging valuation. 

* 4: 4t 

The literary program contained many papers that afforded excellent 
food for thought and action. Doctor Mayo, in his presidential address. 



AMERICAN MEDICAL ASSOCIATION MEETING. 271 

discussed "The Medical Professicm and the Issues which Confront It," 
considering the profession and the public ; public health legislation ; med- 
ical education, state licensure, and reciprocity; relations to insurance 
companies, corporations, et cetera ; the practice of medicine as a business ; 
and concluded with a peroration on medical progress, from which this 
beautiful passage is reproduced : "What are the rewards of so laborious 
a life? They cannot be measured, because there is no standard of com- 
parison. To realize that one has devoted himself to the most holy of all 
callings, that without thought of reward he has alleviated* the sufferings 
of the sick and added to the length and usefulness of human life, is a 
source of satisfaction that money cannot buy. I know many a man 
grown gray in the profession with little of a tangible nature to show as a 
result of his work, but who is not only contented with his lot, but proud 
to have served in the ranks, and who looks back on a life of privation and 
hardship for the benefit of humanity as a privilege which he is thankful 
has been vouchsafed him." ^ Among the various contributions to the 
sections were several which discussed' the conduct and practices of 
physicians themselves. Doctor Jacobi, of New York, read a paper on 
"Quackery," in which he declared that physicians were responsible in 
great degree for the self-dosing with patent medicines. Many doctors 
prescribe nostrums and support medical journals that publish "reading 
notices," that publish advertisements of drugs in the guise of "original 
articles," and that alternate medical with advertising pages. If Doctor 
Dock, of Michigan, discussed "Proprietary Medicines and Their 
Abuses." The exclusion of advertising laudatory of these products 
would not be likely to elevate the morals of physicians already employ- 
ing them in practice. The most efficacious proprietary medicaments 
would continue to be manufactured and advertised, but crude exper- 
imentation could be discouraged by treating the advent of new drugs 
as lightly as one would treat a new phase of mental healing or a new 
application of massage. The abuse of proprietary medicines sprang 
partly from the exaggeration of legitimate commercial methods, and 
partly frcMn the credulity of the medical profession. It is within the 
province of the profession to determine the virtue and vogue of every 
medicinal product recommended for the treatment of disease. IfAt a 
meeting of medical editors, Doctor Pilcher, of Pennsylvania, contrib- 
uted a paper in which medical editors were classified and defined, a 
summary of opinion being embraced in the following: "We conclude, 
then, (i) that while medical journalism as a prop to practice and a 
bridge over the impecuniosity of early professional years may be of some 
advantage to the profession as well as to the temporary editor ; (2) that 
while medical journalism for the purpose of developing special lines of 
• professional and mercantile work may be of much service to many of the 
profession ; (3) that while there are a small number of men who possess 
the exceptional executive and literary ability necessary to conduct pro- 
fessional and editorial work at the same time — ^the medical journalism 
of the twentieth century increasingly demands the whole intellectual and 



272 EDITORIAL COMMENT. 

physical energy of its editorial conductors in the presence of the great 
aggregation of professional atoms which is daily falling upon the profes- 
sional field to be excavated and investigated, and the during away of 
which, for the benefit of the twentieth century practitioner, will demand 
the entire absorption of the mind, soul, and body of the conscientious 
medical editor who really desires to be a helper to the profession and a 
leader in the medical work of the age." 



ANNOTATIONS. 



THE INFLUENCE OF MINERAL WATER ON MICROBES. 

Rheinbolt, in a German publication, describes his experiments on 
the bacillus prodigiosus with radioactive mineral water. That minerals 
of all kinds exert a deteriorating influence <mi bacteria is a well-known 
fact, and that mineral water is also an inhibitant to bacterial growth was 
disclosed by the experiments of this scientist. While old water, bottled 
for commercial purposes, seemed to have lost its attenuating power, 
fresh specimens, taken from the spring, destroyed the organisms in a 
boullion culture after a contact of four hours, the activity of the water, 
however, decreasing after this time. Efforts to recharge the liquid with 
radium emanations proved to a degree futile, and this fact is responsible 
for the conclusion that mineral water possesses inhibitory properties 
other than are represented in this metal. 



INVESTIGATIONS BEARING ON ANIMAL INTELLIGENCE. 

The study of animals, the degree of their intelligence, the acuteness 
of their vision, and the capacity of their comprehensicMi is indeed interest- 
ing. However, owing to our inability to decipher their vernacular, or 
whatever phonetic means of communication they may possess, we are 
unable to successfully penetrate their mentality. Zell has studied the 
subject quite comprehensively, and in a contribution to a German publi- 
cation details his observations. That monkeys are equipped with a keen 
sense of sight he is convinced, and that their power of discrimination is 
above the ordinary he determined when studying the quadrumana in the 
Berlin Zoological Garden. Contrary to the usual spirit of audacity which 
characterizes these animals, one of them utterly ignored the visitors and 
concentrated her attention on a street vehicle, seemingly wrapped in deep 
thought. On asking the keeper the cause of her concern the observer 
was informed that instead of the customary horse the conveyance was 
attached on this occasion to a donkey, and the aural appendages and 
other equine dissimilarities had incited her curiosity. Monkeys are 
equipped with a comparatively poor olfactory apparatus, and must 
depend almost entirely upon their sense of sight to warn them of the 



PHYSICIANS AND PHILOSOPHERS. 273 

approach of animals of prey and other malefactors. Dogs, on the other 
hand, so far as scientists have been able to determine, have an excellent 
sense of smell, but of the power of their optical adjustment little is 
known. Deer and roebuck have comparatively poor eyes but excellent 
noses. Observation has taught that animals are more vindictive to 
enemies than is man, and in consequence of the constant vigil which 
beasts of the jungle must maintain on account of the murderous assaults 
of preying foes, nature has wisely endowed them either with keen percep- 
tion or acute sense of smell. 



STOICISM OF EARTHQUAKE SUFFERERS. 

The stoicism with which Californians view the calamity to the city 
of San Francisco is displayed in an article which lately appeared in a 
western publication. In comparing the deaths resultant from the earth- 
quake to those sustained in recent American catastrophes the utmost 
optimism is exhibited. In the Iroquois theater conflagration in Chicago 
more than five hundred persons met death, and over one thousand lives 
were sacrificed in the burning of the steamer "Slocimi" in New York 
harbor. Thus it will be seen that sinc^e only three hundred thirty-three 
persons succumbed from fire and quake in the California metropolis, the 
loss, while appalling, is c<Mnparatively small. The author argues that 
within the course of a few weeks more than three hundred persons would 
have died from natural causes, and inasmuch as hundreds of births will 
occur in San Francisco within a year, the depopulating effect of the dis- 
aster is not so severe as would at first be imagined. Indeed, when con- 
trasted with other catastrophes, the death list is insignificant. 



CONTEMPORARY. 



PHYSICIANS AND PHILOSOPHERS. 

[pmoraaaoK chaklbs william supkr, ov omio vnivbrsitt, in populak scibmck monthly.] 
{C»niinu4d from ^ag» 2t3b.) 

According to Homer and Herodotus, the healing art was discovered 
or invented in Egypt. The Odyssey tells us that there every man is 
a physician skilled beyond human kind. Mention is also made of the 
many plants possessing medicinal properties. Oculists are said to 
have been particularly numerous, and many prescriptions for diseases 
of the eye have been found among the papyri. Artificial and gold- 
filled teeth have also been met with both in Egypt and in Etrurian 
tcrnibs. The practise of medicine was, however, purely empirical, and 
the rules followed in the treatment of particular diseases were often 
of great age. The second king of Egypt is said to have been a physi- 
cian, and another is reported to have written a book on anatomy. The 
private physicians of both Cambyses and of Darius were Egyptians. 



274 EDITORIAL COMMENT. 

The name of the latter brings to mind that of his son Artaxerxes whose 
private physician was a man of considerable importance in his day, 
outside of his profession. Ktesias was a native of Knidos, a contem- 
porary of Hippocrates, and no doubt personally known to him. Here 
we have again the philosopher and the physician in the same person. 
After acquiring considerable reputation in his own country he had the 
misfortune to fall into the hands of the Persians. Subsequently he 
was introduced at court, which proved the beginning of his good 
fortune. After the battle of Cunaxa he healed the wound inflicted upon 
his master by the brother of the latter. Later he was employed on a 
diplomatic mission to his native land; and thus after an absence of 
seventeen years returned home about 398 B. C, to remain for the rest of 
his life. That he was well treated by the master whose slave he became, 
according to Persian parlance, and had abundant opportunities for 
study, is evident from the fact that he compiled a 'History of Persia,' 
a work in which he charged Herodotus with frequent falsehoods in 
what he relates about that country. His scholarly tastes are evinced 
by this extensive collection, as it must have been, since it was divided 
into twenty-three books. He also composed a small work on India 
and one on geography. He is not known to have left any medical 
writings, and his reputation for impartiality as a historian is not very 
good. Still it must be regarded as a great misfortune that his extant 
remains are so meager. 

In later times many Egyptian physicians practiced in Rome ; for to 
have studied in the land of the Nile, or, still better, to have been bom 
there, was regarded as a special recommendation. Here, too, magic 
formulas of all kinds were in frequent use, not only in the compound- 
ing of medicines, but in their application. According to Pliny cadavers 
were dissected by order of the Ptolemies for the purpose of studying 
fatal diseases. But it can hardly be inferred from this statement that 
anatomy was regularly pursued in this way, or that dissection was a 
common practice. 

Pliny, who had no very high opinion of the medical fraternity for 
reasons that will appear farther on, makes the assertion that Rome 
managed to get along six hundred years without physicians. This is 
manifestly an exaggeration, since many Greeks professed the healing 
art in the imperial city much" earlier than 150 B. C. But neither did 
Rome produce a philosopher in the proper sense of the term ; certainly 
no man who loved wisdom for its own sake. The Romans were, how- 
ever, an exceptionally healthy people, owing to their fondness for out- 
door life. This is demonstrated by the rapidity with which they recov- 
ered from repeated disasters. Once in a while their capital was invaded 
by a contagious disorder, then all who could do so left it until the 
scourge had spent its force, when affairs resumed their natural channel. 
In fact this was the usual course everywhere until very recently, when 
the real nature of such diseases was discovered. The ancient Romans 
were also a singularly hard-headed and practical people ; consequently 



PHYSICIANS AND PHILOSOPHERS. 276 

they were almost entirely free from the long list of complaints that 
are more or less due to the uncontrolled or uncontrollable imagination. 
Shortly after the Punic wars, but especially under the empire when 
luxurious habits due to the influx of wealth from the east had debili- 
tated the naturally robust constitutions of the higher classes, nervous 
disorders, along with many others, were inevitable. Then quacks, 
charlatans, medicasters, soothsayers, magicians, astrologers and what 
not found a ready market for their wares. They played upon the cre- 
dulity of the populace and preyed upon their purses because there was 
money in both the playing and the preying. No small portion of them 
probably were shrewd enough to disguise some real medical knowledge 
under a mass of hocus pocus in order to influence the imaginations of 
their patients. Well might Ovid say as others had said before him — 
and since, too—mundus vult decipi (people like to be deluded). Phy- 
sicians still give to their patients who insist 'on taking something' bread 
pills, colored water and other equally potent or impotent remedies. It 
would be manifestly unfair to charge a physician with dishonesty 
because he practices a harmless ruse upon a patient who can be helped 
in no other way so easily. 

"Dismissing faith in the confused creeds of the heathen world, he 
reposed the greatest faith in the power of human wisdom. He did 
not know (perhaps no one in that age distinctly did) the limits which 
nature imposes on our discoveries. Seeing that the higher we mount 
in knowledge the more wonders we behold, he imagined that nature not 
only worked miracles in her ordinary course, but that she might, by 
the cabala of some master soul, be diverted from that course itself. 
Thus he pursued science across her appointed boundaries into the land 
of perplexity and shadow. From the truths of astronomy he wandered 
into astrological fallacy ; from the secrets of chemistry he passed into 
the spectral labyrinth of magic; and he who could be skeptical as to 
the power of the gods was credulously superstitious as to the power 
of man." Such are the thoughts that Bulwer-Lytton, in the Last Days 
of Pompeii, puts into the mind of one of his characters, the Egyptian 
Arbaces. The reasoning by which such men justified the employment 
of their superioi: knowledge and insight to dupe the credulous was 
half philosophy, half knavery. If a man is the possessor of power 
unknown to the multitude except in its effects, why has he not the 
right to use it? — to use it first of all to enhance his authority and to 
draw from such authority the advantages that seem to him most desir- 
able ? We may well admit that a man of this stamp may have had an 
inward feeling akin to what we call conscience that would justify his 
attitude toward his fellows — ^yet he did not consider these Romans 
fellow men of his — but it was wholly of the intellect. Such a man is 
as much a philosopher as were the sophists of an earlier age, and, we 
may add, of our own day. They apprehend clearly certain superficial 
verities, but cease to inquire farther after they have discovered what 



276 EDITORIAL COMMENT. 

they think needful and sufficient for their own aggrandizement Far 
different was the class of witches, one of whom is introduced in the 
same novel. Against these Horace frequently raises his voice, as do 
also others of the rationalizing Romans. They are ignorant, and, in 
most instances, as much the dupes of their own juggleries as their 
victims. Every man who goes through the world with his mind alert 
can see specimens without especially looking for them. It is doubtful 
whether any man has ever lived who had not at least a modicum of 
superstition in him. However much we may know and however far 
we may be able to pry into nature in some directions, there are others 
in which our vision is barred and the unknown is literally within arm's 
length. The mystery of life and death has always been so profound, 
as it still is, though in a different way, that we need not wonder at the 
strange aberrations which so many persons fell into, who were in most 
matters little likely to be carried away by delusions. Sleep, 'the twin 
brother of death,' has from time out of mind been regarded as an 
excursion into the realm of departed spirits. If, as many believe, our 
consciousness is never coextensive with our personality, there are yet 
many discoveries to be made not dreamt of in the philosophy of most 
of us. Our will as an integral part of ourselves is the resultant of so 
many forces and, with the majority, is so little under control of rational 
motives, that it often plays fantastic tricks, not before high heaven 
alone, but almost anywhere. 

The will of each individual as modified, at least in action from 
moment to moment, is like a ball thrown into a grove. It strikes one 
tree, then another and another, and no one can predict with certainty 
where it will come to rest. This element of chance, of Tyche, in the 
affairs of men, this incalculable calculus of probabilities, pervades in 
a remarkable degree the literature of ancient Greece and Rome. It 
made many feel that, do what they would, they were doomed to be 
thwarted in their plans. It was only those who, like Socrates, Epictetus 
and a few others, maintained that the chief end of man is to be found 
in motives rather than in outward results, who were never thrown out 
of their philosophical poise by the strange vicissitudes of life. 

It is a far cry from the Greeks to the Saracens, though farther in 
time than in space. Here we find philosophy, or rather metaphysics, 
and medicine more intimately associated than at any other time or 
among any other people. Every one of the ten or twelve men who 
became prominent in Arabian philosophy was a physician. In fact the 
Arabs treated philosophy as a branch of astronomy and the healing art. 
The latter served a practical purpose, as did also the former in so far as 
it was dealt with as astrology. Arab philosophy was, however, some- 
thing very different from the science that bore the same name among 
the Greeks. They studied philosophy, or rather they philosophized, 
as a man would study navigation on a ship lying at anchor. Albeit 
they were in this respect at no greater disadvantage than the school- 
men. The one party was chiefly concerned to make any discoveries 



PHYSICIANS AND PHILOSOPHERS'. 277 

they might light upon hannonize with the Koran and Aristotle; the 
other with the Bible and Aristotle, with a little spice from Ptolemy 
thrown in. Al-ldndi, the philosopher par excellence of the Arabs, 
flourished in the tenth century. He wrote on almost every imaginable 
subject from arithmetic to astronomy, though under the former he dis- 
cusses the unity of God ; his arithmetic was therefore something totally 
different from that which forms the schoolboy's triangle with readin' 
and 'ritin'. So far as is at present known all his works are lost, except 
those on medicine and astrology. Roger Bacon ranks him in some 
respects close to Ptolemy. Al-farabi was a contemporary of the pre- 
ceding and is generally regarded as the earliest of the Arabian philos- 
ophers. However, medical science and even surgery could make little 
progress where the knowledge of human anatomy was so inadequate. 
The Koran denounces as unclean every person who touches a dead 
body, and an article of Mohammedan faith forbids dissection. We 
should remember, nevertheless, that the founder of anatomy, Vesalius, 
was sentenced to death by the Inquisition as a magician, and only par- 
doned on condition that he make a pilgrimage of penance to Jerusalem. 
This journey cost him his life. And it is probable that he would not 
have got off even on these relatively hard terms had he not enjoyed the 
favor of Philip H of Spain, who esteemed him highly for his medical 
skill. We have the name of one Arab physician, Abdallatif of Bagdad, 
who was well aware that anatomy could not be learned from books, 
strange as it may seem that historians have thought it worth while to 
place to any man's credit a truth so easily apprehended. The same 
authority avers that Moslem doctors studied that branch of anatomy 
known as osteology by examining the bones of the dead found in cem- 
eteries. Averroes of Cordova fills a large place in the history of Moor- 
ish philosophy in Spain about the middle of the twelfth century. But 
in medical renown he ranks far below Avicenna of Bokhara, who 
flourished about a century and a half earlier. He was teacher of both 
philosophy and medicine in Ispahan. His medical works seem to have 
been the chief guide in this branch in Europe for almost five centuries ; 
their sway was not broken until the beginning of the seventeenth cen- 
tury. It is strong and yet painful testimony to the inherent stupidity of 
mankind, physicians not excepted, that the doctrines of Avicenna are 
little more than what is found in Galen somewhat modified by Aris- 
totle ; and, as we have seen, Galen represents no great advance upon 
Hippocrates. Alas for the human race that it has always been so much 
easier to memorize than to think and to investigate! The medical 
science and practice of the Arabs was confined chiefly to surgery and 
the empirical treatment of internal diseases. There was no lack of 
victims in view of the constant wars in which the califs were engaged, 
and no lack of opportunity for the study of disease in its various forms 
in the hospitals which some of them founded in various parts of their 
domains. 

[TO Bl CONTINUED.] 



278 MEDICAL NEWS. 

MEDICAL NEWS. 



THE NATIONAL MEDICAL ELECTION: 

Doctor Joseph D. Bryant, of New York City, was elected pres- 
ident of the American Medical Association at its recent meeting in 
Boston. Other officers chosen on this occasion are as follows: First 
vicepresident, Doctor Herbert L. Burrell, of Boston; second vice- 
president, Doctor Andrew C. Smith, of Portland ; third vicepresident, 
Doctor David S. Fairchild, of Des Moines; fourth vicepresident. 
Doctor William S. Foster, of Pittsburgh; general secretary, Doctor 
George H. Simmons, of Chicago ; treasurer, Doctor Frank Billings, of 
Chicago; trustees, Doctor Malcolm L. Harris, of Chicago, DoctcM* 
William H. Welch, of Baltimore, and Doctor Miles F. Porter, of Fort 
Wayne. 

COMMENCEMENT SEASON CLINIC. 

Clinic week is always an important feature of commencement sea- 
son at the Detroit College of Medicine, but the event this year is 
pronounced more consequential than ever before, as many as three 
hundred witnessing some of the clinics, and five hundred being con- 
servatively estimated as the total attendance. In addition to the regular 
teaching force of the college, clinics were conducted by Doctor George 
Dock, of Ann Arbor, on diseases of the heart; Doctor Edward G. 
Tuttle, of New York, on rectal diseases; Doctor Bart E. MacKenzie, 
of Toronto, on orthc^dic surgery; and Doctor Howard A. Kelly, of 
Baltimore, on operative gynecology. The advent of the scientific and 
social features of the occasion was marked by a symposium on "Crim- 
inal Abortion" before the Wayne County Medical Society, the partici- 
pants being Doctor Howard W. Longyear, of Detroit, who discussed 
the question from the medical standpoint ; Attorney Charles Lightner, 
of Detroit, who considered the legal aspect of the question ; and Rev- 
erend Father Command, of Trenton, who defined the attitude of the 
Church toward the murderous practice. 



THE PENINSULAR GATHERING OF PHYSICIANS. 

The forty-first annual meeting of the Michigan State Medical 
Society was held at Jackson, May 23, 24, and 25. The program 
embraced the titles of over fifty papers, besides three orations and two 
addresses, the latter being delivered by Doctor John B. Murjrfiy, of 
Chicago, and President David Inglis, of Detroit. "Education" was 
the subject of the presidential discourse, and the views enunciated con- 
template not only better means of educating the physician but better 
means of educating the public as well. The trend of ideas is especially 
reflected in the suggestion that county societies disseminate informa- 



LIFE INSURANCE EXAMINATION FEES. 279 

tion among the laity regarding the prophylaxis of venereal diseases; 
that a committee on medical educaticm be appointed from the State 
Society to cooperate with the Q>uncil of the American Medical Asso- 
ciation; that amalgamation of medical schools affords the greatest 
efficiency in properly training medical students, and hence the desira- 
bility in Michigan of merging the State University medical school and 
the Detroit College of Medicine. The quality of the papers was equal 
to the average of previous meetings, while the symposiums in the 
sections afforded exceedingly delightful variation. The Society 
recommended the c(xnbination of medical colleges; addition to the 
faculties of medical colleges of a chair on Professional Ethics ; investi- 
gation of contract practice for fraternal orders and for poor commis- 
sioners ; refusal to accept reduction of fees for life insurance examina- 
tions ; and modification of existing laws to enable more efficient deal- 
ing with tuberculous cattle. It was decided to return to a two-days' 
session and to omit the orations. A vote of thanks was tendered 
Doctor Leartus Connor for services rendered in reorganizing the State 
Society, and a committee was appointed to select a testunonial for 
Doctor Andrew P. Biddle in recognition of his services as secretary. 
The following officers were elected for the ensuing year: President, 
Doctor Charles B. Stockwell, of Port Huron ; first vicepresident. Doctor 
William Fuller, of Grand Rapids ; second vicepresident. Doctor Edward 
T. Abrams, of Dollar Bay; third vicepresident, Doctor Delbert Rob- 
inson, of Jackson; fourth vicepresident. Doctor Allison R, Stealy, of 
Charlotte. The following were elected chairmen of sections: Med- 
icine — ^Doctor Joseph B. Whinery, of Grand Rapids ; Surgery — ^Doctor 
Louis A. Roller, of Grand Rapids; Gynecology — Doctor Walter H. 
Sawyer, of Hillsdale. The next meeting will be held at Saginaw. 



LIFE INSURANCE EXAMINATION FEES. 

The question of compensation for life insurance examinations was 
considered at the recent Jackson meeting of the Michigan State Medical 
Society, and the concensus of opinion was expressed in the following 
preamble and resolutions: ' 

Whereas, Many of the Life Insurance Companies havQ notified their 
medical examiners of a reduction of the examining fee from $5.00 to 
$3.00, and 

Whereas, We, as physicians, realizing the responsibility incident to 
proper examination of the individual, believe such reduction to be 
unjust, therefore, be it 

Resolved, That the House of Delegates, in session assembled, does 
hereby declare such reduction to be unjust, and respectfully requests 
that no physician legally authorized to practice medicine in Michigan, 
accept such reduction of fees. 

Resolved, That it is the sense of the House of Delegates that here- 
after in such examinations for life insurance, the minimum fee shall 
be $5.00. 



280 MEDICAL NEWS. 

Resolved, That the several component societies forming this State 
Society, be requested to adopt these resolutions. 

Resolved, That a copy of these resolutions be mailed to the several 
life insurance companies that have reduced the fee from $5.00 to $3.00. 

At the Boston meeting of the American Medical Association, Doctor 
Mayo, in his presidential address, referred to the question of fees for 
life insurance examinations in the following terms : 

"We come now to consider some abuses from which the physician 
suffers. It is a matter of professional pride that, in the general con- 
demnation of the life insurance companies, although every other part 
of the control has been shown to be corrupt, no breath of scandal has 
touched the medical department. Yet the local examiner has the most 
cause of all to be dissatisfied. The New York Life, some years ago, 
cut the fee for examination forty per cent, apparently not as a matter 
of ecgnomy, for at that time the most corrupt practices existed, but 
rather to enable the agent more easily to pass 'new business' at any 
cost. This action has lately been imitated by the Equitable and some 
others and has resulted in forcing the resignation of many of their best 
examiners. The general officers have taken great credit on themselves 
for voluntarily reducing their salaries twenty per cent. It is a rank 
injustice that the one body of men who have emerged clean from the 
insurance scandals should suffer the most for the crimes of others. 
A thorough medical examination to prevent fraud by the admission of 
unsafe risks is essential. With few exceptions the line companies pay 
a fair fee and less should not be accepted. The casualty Companies, 
such as the Maryland, are the worst offenders, and some concerted 
action should be taken to compel them to mend their evil ways." 

Acting upon the suggestion of the President the following resolu- 
tion was introduced and referred to the Committee on Miscellaneous 
Business : 

Resolved, That a standing committee on insurance is hereby created 
to consist of five members, two of whom shall be the President and 
Secretary, and the other three to be nominated by the President and 
confirmed by this House of Delegates. It shall be th duty of the com- 
mittee to consider the relations and duties of the medical profession of 
this country to the insurance business, both companies and policy 
holders to confer, treat and act with authorized representatives of any 
of these interests, and it is authorized to speak and act for the profes- 
sion in all matters relating to its duties and to give publicity to its 
plans and purposes at any time through The Journal, or otherwise, as 
may be deemed best. 

This committee, which includes, besides the President and Secretary, 
Doctors E. Elliot Harris, Albert D. Price, and William D. Haggard, 
submitted the following resolution to the House of Delegates : 

Resolved, That a committee be created to consist of five members, 
two of whom shall be the President and the President-elect and the 



LIFE INSURANCE EXAMINATION FEES. 881 

Other three to be nominated by the President and confirmed by the 
House of Delegates. 

That they shall consider the insurance question in its relation to the 
medical profession, and it shall have power to act and confer with the 
representatives of the insurance cc«npanies and policy-holders on behalf 
of the medical profession represented by this Association. 

It shall give publicity to its plans and purposes at any time in The 
Journal or as may be deemed best. 

That the resolution of Doctor D. M. Work, of Colorado, asking for 
an endorsement in the matter of the examination fee question which 
has been confirmed by many county medical societies. 

That the Committee recommends that it is in spirit with it ; yet in 
view of the fact that a committee is created to deal with these questions, 
it asks that the resolution in question be referred to the Committee on 
Insurance. 

The following Committee on Insurance was tjien appointed by the 
Chair: 

John H. Musser, Pennsylvania, Chairman ; William H. Mayo, Min- 
nesota; Joseph N. MacCormack, Kentucky; Joseph D. Bryant, New 
York; Frank Billings, Illinois. 

The resolution of Doctor Work alluded to in the resolutions of the 
Committee on Miscellaneous Business, is as follows: 

Resolved, That the American Medical Association heartily endorses 
the action of many of its component county societies in their refusing 
to accept a reduction of the fees heretofore paid for life insurance 
examinations by certain so-called old-line companies. 

This is the status of the matter as considered by the Michigan State 
and American Medical Associations. At the seventh annual meeting 
of the American Association of Life Insurance Examining Surgeons, 
which was lately held in Boston, the question of fees was discussed. 
This association is composed of physicians who are closely identified 
with the present agitation, and consequently the following preambles 
and resolution, adopted by that body, will be of exceeding interest : 

Whereas, It is generally understood by every practitioner through- 
out the country that the examiner who does his full duty must often 
cause the rejection of undesirable risks and the consequent loss of busi- 
ness to the company and of commissions to the soliciting agent; and, 

Whereas, The interests of the insured and the welfare of the com- 
pany represented by the examiner make it necessary for him to exercise 
his judgment, to make a careful diflFerentiation of risks and to try by 
every means in his power to recommend only those applicants whose 
physical condition is up to the standard and whose examination dis- 
closes no undue influence which might prevent the living out of the 
estimated expectancy; and, 

Whereas, Recent disclosures in connection with life insurance aflFairs 
have demonstrated (i) inexcusable negligence, (2) criminal careless- 
ness, (3) dishonest practices on the part of the highest executive 



282 MEDICAL NEWS. 

officers, and a total abandonment of the responsibility always pertaining 
to a trusteeship, in a concerted e£Fort for personal profit ; therefore be it 

Resolved, That we favor the complete separation of the medical 
from the executive department of every mutual insurance company. 

We favor the election of the medical director in the same way and 
manner as the election of the executive officers, namely, by diro:t vote 
of the policy-holders. 

We favor suitable legislation in all States, with a view of making 
this recommendation effective. 

We depreciate the action on the part of certain state and country 
medical societies to assert that members shall be expelled from mem- 
bership or shall be deprived of the privilege of consultation with their 
fellows unless they agree under no circumstances to make an examina- 
tion for less than $5. We agree that a reduced fee is inadequate to 
the value of the service rendered, but we assert that no hardship should 
be imposed upon the individual practitioner. We favor in place of this, 
to enter an earnest protest against the attempt of certain companies to 
reduce the fee. We assert most positively that economy in insurance 
methods should not begin with the medical examiners — ^it should take 
cognizance of the irregularities — ^to use no harsher word — ^which the 
Armstrong investigation has brought to light It should favor reform, 
but it must maintain an efficient corps of medical examiners, which is 
only possible by paying a fee to some degree commensurate with the 
importance of the service rendered. 



MINOR INTELLIGENCE. 



Doctors Charles D. Aaron and Gilbert S. Field, two Detroit 
physicians, are in Europe. 

The next meeting of the American Medical Association will be 
held at Atlantic City, New Jersey. 

The osteopathic licensing bill, which recently passed the New York 
Senate, was afterward revoked by the Assembly. 

Doctor Hal C. Wyman, of Detroit, and Miss Lulu Weeks, of 
Mount Vernon, New York, were united in marriage on June 12, at 
the home of the bride. 

An amalgamation of the old territorial medical associations of 
Oklahoma and Indian Territory has been effected, and the new organ- 
ization will henceforth be known as the Oklahoma State Medical 
Association. 

This year's meeting of the British Medical Association will be 
held in Toronto, Canada, ^rom August 21 to 25. A large attendance 
is anticipated both from England and from the United States. The 
address in Medicine will be delivered by Sir James Barr, and the 
address in Surgery by Sir Victor Horsley. 



MINOR INTELLIGENCE. 283 

Doctor F. F. Westbrook has been elected to the deanship of the 
Minnesota University department of medicine and surgery, vice Doctor 
Parks Ritchie, resigned. 

Doctor George Blumer, formerly professor of pathology and bac- 
teriology in the Albany Medical College, has been appointed to fill the 
chair of medicine at Yale University. 

A BILL appropriating a total of $350,000, or $50,000 annually for 
seven years, for the work of exterminating the mosquito has been 
signed by Governor Stokes of New Jersey. 

The Order of the Rising Sun has been cgnferred upon Doctor 
Jokichi Takamine, the well-known Japanese chemist of New York 
City, by His Majesty, the Emperor of Japan. 

Plague continues to reap a fearful harvest in India. During the 
week ending April 28 over one thousand seven hundred deaths out of 
a possible twenty thousand cases were reported. 

Doctor Bacon, a prominent Connecticut physician who died 
recently, left a legacy of $100,000 to the Hartford Medical Society. 
The bequest will be utilized as an endowment fund. 

Doctor Theodore A. Felch, of Ishpeming, has been appointed a 
member of the Michigan State Board of Registration in Medicine, vice 
Doctor Joseph B. Griswold, of Grand Rapids, resigned. 

Mayor McClellan, of New York City, has appointed a commission 
to cooperate with a like body from Jersey City in the establishment of 
protection of the waters of the harbor against pollution. 

The Health Department of Chicago will shortly gain possession 
of the eight municipal ambulances which have been under police con- 
trol. The vehicles will then be under medical supervision. 

The new medical buildings of Harvard University will be dedicated 
this fall, the ceremonies being scheduled for September 25 and 26, 
1906. Faculty invitations have already been issued to alumni. 

Doctor Albert Becket Lamp, formerly of Harvard University, 
has been appointed to the directorship of the Havemeyer Laboratory 
of Chemistry, New York University, vice Doctor Morris Loeb. 

In connection with the opening of the new cancer research labora- 
tory at Heidelberg, an international congress on the subject is con- 
templated. The event will be held from September 24 to 27, 1906. 

Doctor Charles W. Pilgrim7 until recently superintendent of the 
Hudson River State Hospital, has been appointed to the presidency 
of the New York State Lunacy Commission, vice Doctor William 
Mabon, resigned. 

The great prevalence of typhoid in Pittsburg and vicinity has led 
the Pennsylvania Commissioner of Health to demand that the cities and 
villages situate on the tributaries of the Allegheny disinfect all refuse 
before dumping it into the streams. 



284 MEDICAL NEWS. 

The American Journal of the Medical Science which, untfl recently, 
has been under the editorial control of Doctor Francis R. Packard, 
will henceforth be guided by Doctor Aloysius O. J. Kelly, who has 
been elevated to the editorial tripod. 

Professor Wilhelm Ostwald has resigned the chair of chemistry 
at the University of Leipzig. Displeasure caused by the indifference of 
coworkers at the institution toward his chemical researches is said to 
be the reason for the relinquishment. 

Milwaukee has an ordinance which compels physicians to report 
injuries which incapacitate the victom for a period of two weeks or 
longer. An average of more than one hundred seventy-five a month 
has been recorded thus far this year. 

The Lyman D. Morse Advertising Agency, well-known medical 
advertising purveyors, has increased its scope, and will henceforth 
be known as the Morse International Agency, with offices at 19 West 
Thirty-fourth Street, New York City. 

The effectiveness of the sanitary regime instituted by the Amer- 
icans in the canal zone is apparent. According to the last official report, 
that region was infested with only one case of yellow fever, and disease 
of all kinds is rapidly being eradicated. 

The House of Representatives passed the Pure Food bill by a vote 
of 240 to 17 on the 23d instant. The enactment differs considerably 
from the original measure proposed by the senate, having been subjected 
to the adoption of several amendments. 

The recent death of Doctor Louis A. Wiegel, of Rochester, New 
York, from burns received in experimenting with the ;r-rays, should 
serve as a warning against undue exposure, especially of the hand, 
when operating radiographic apparatus. 

The Minnesota State Board of Health has decreed that henceforth 
tuberculous teachers shall not be employed, inasmuch as confinement 
in school buildings not only militates against the recovery of teachers 
but endangers the health of the children as well. 

The plaintiff .in a damage suit which recently occurred in Nebraska 
was granted a verdict for $600 against a physician for injuries allied 
to have been received in an jr-ray examination for the detection of a 
vesical calculus. Damages to the extent of $6,000 were claimed. 

Doctor John J. Marker has been reappointed general superin- 
tendent of the Wayne County Home at Eloise. Other positions filled 
by the Superintendents of the Poor are: assistant superintendent, 
Doctor William B. James ; house physician. Doctor Romeo H. Earl. 

A SOCIETY for the promotion of cremation has been formed in 
Belgium. Inasmuch as this method of disposal has not gained foothold 
to an appreciable degree in that country the new organization will 
conduct a campaign by means of lectures, tracts, expositions, et cetera. 



MINOR INTELLIGENCE. 286 

The French government has accorded Madame Curie, wife of the 
discoverer of radium, a pension of 12,000 francs per annum. Besides 
this income she will have the salary connected with the chair of Physics, 
in the University of Paris, to which she has recently been appointed. 

The Philadelphia Board of Education is agitating the advisability 
of employing a corps of trained nurses to work among the school 
children of that city. Because of the appropriation incident to the 
departure, such a bill would be likely to receive a negative vote in the 
city council. 

The Buffalo city hospital for the care of patients suflFering from 
contagious diseases is rapidly nearing completion. The erection of 
the new building has necessitated an expenditure of over $50,000, and 
in range of equipment the institution will be one of the best appointed 
in the state. 

The study of alcoholism has been introduced into the curriculum 
of the University of Berlin. The subject will be demonstrated from 
all phases — the influence of alcoholic indulgence on the mental develop- 
ment of the young, its relation to insurance, its effects on the physical 
powers, et cetera. 

Cocktails adulterated with wood alcohol are responsible for two 
deaths which occurred recently in Brooklyn, New York. A ten-gallon 
keg of the wood product was found on the premises of the saloonkeeper 
who dispensed the decoction, and the rascal has been arrested on a 
charge of homicide. 

A charter was recently granted in New York to the American 
Institute for Scientific Research, which had its inception in the Society 
for Psychical Research. The new body was organized primaril]f to 
investigate conditions of abnormal psychology and to place the study 
on a scientific foundation. 

New Rochelle, New York, is to have a new hospital. Mr. C. O. 
Iselin has pledged himself to contribute $40,000 toward the project, 
providing the citizens of the town subscribe $60,000, and thereby 
facilitate the erection of a modern building. Twenty thousand dollars 
has already been collected. 

The Pennsylvania State Board of Health has inaugurated a course 
of instruction for persons suffering from or exposed to transmissible 
diseases. The knowledge is dispensed by means of circulars, and com- 
prises practices regarding the care of afflicted as well as precautions 
calculated to insure prevention. 

The Chicago Medical Society elected the following officers at its 
annual meeting on June 20: President, Doctor George W. Webster; 
secretary, Doctor Robert T. Gillmore; councilors, Doctors William A. 
Evans, Charles S. Bacon, Frank Billings, Lewis L. McArthur, and 
Farnand Henrotin; alternates, Doctors William E. Quine, Henry F. 
Lewis, Winfield S. Harpole, Brown Pusey, and Theodore Tieken. 



286 MEDICAL NEWS. 

The Dental Alumni Association of the University of Pennsylvania 
has erected a bronze tablet in Dental Hall to commemorate the late 
Doctor Charles J. Essig, one of the country's foremost workers in the 
dcHnain of dentistry, and professor of dental mechanics and metal- 
lurgy in the Quaker institution. 

The records of the California State Medical Society were lost in 
the recent disaster. As a peculiar coincidence the society met in San 
Francisco on April 17, 1906, the day before the catastrophe, and on the 
morning of the i8th — in front of the ruined convention hall — ^the 
meeting was declared adjourned. 

German Southwest Africa is to be converted into a receiving 
station for tuberculous Teutons. Evidently the sanatorium system as 
conducted in Germany has not produced the most desiraUe results, 
and since the climatic conditions in Germany's portion of the dark 
continent are ideal for the consumptive, the government has decided 
to test the plan by sending a number of afflicted working people to the 
continent. 

The hospital system of San Francisco suffered severely from the 
recent earthquake, all but three or four being rendered useless. The 
Children's Hospital was one of those which remained intact, and its 
inmates are receiving the attention of Doctor Hezadiah Crabtree. A 
Maternity Hospital has been established at Berkeley University, and 
prospective mothers are thereby assured proper care during the 
puerperium. 

The Indiana State Medical Association held its annual meeting at 
Winona Lake on May 23-25, 1906. Following are the officers elected 
for the coming year: President, Doctor George J. Cook, of Indian- 
apolfs ; vicepresidents, Doctor John B. Berteling, of South Bend, and 
Doctor Charles J. Chittick, of Frankfort; secretary, Doctor Frederick 
C. Heath, of Indianapolis ; treasurer, Doctor Albert E. Bulson, Jr., of 
Fort Wayne. 

The medical section of the Newberry Library, Chicago, has been 
consolidated with the John Crerar Library of the same city. Together 
with the library proper. Doctor Senn has given permission for the 
transfer to the Crerar Library of the Senn Collection on Medical His- 
tory. At present the quarters of the John Crerar Library are inade- 
quate to accommodate the change, and a new building is being erected 
as quickly as possible. 

The New York State Commission in Lunacy will erect a State 
Reception Hospital and Dispensary for the Insane. The Board of 
Estimates and the Aldermen of New York City have authorized the 
purchase of a piece of property 200 x 250 feet between Seventy-third 
and Seventy-Fourth Streets, overlooking the East River, for the pur- 
pose. The land will cost $146,000, and it will be leased to the state. 
The Lunacy Commission will expend $300,000 in buildings. 



MINOR INTELLIGENCE. 287 

After a more or lesc successful career of twenty-three years, the 
Ontario Medical College for Women has been discontinued, owing to 
the establishment of coeducation in the Medical Department of Toronto 
University. The attendance has been growing smaller each year, and 
a disruption was the inevitable outcome. 

One hundred two candidates received the degree of Doctor of 
Medicine in Philadelphia on June 13, the event being the CMie hundred 
fiftieth commencement of the University of Pennsylvania. The address 
of the occasion was delivered by Professor John Bach McMaster, of 
the history department of the University. 

The thirtieth annual meeting of the American Dermatological Asso- 
ciation was held in Qeveland, Ohio, May 31 and June i and 2, 1906. 
The following officers were elected for the ensuing year: President, 
Doctor Arthur Van Harlingen, of Philadelphia; vicepresident, Doctor 
William A. Pusey, of Chicago; secretary-treasurer, I)octor Grover W. 
Wende, of Buffalo. A number of excellent papers were read and dis- 
cussed, among them being one by Doctor William F. Breakey, of the 
University of Michigan. 

The Chicago Medical Society has been considering the "contract 
practice" question. A protest was raised by the Douglas Branch of this 
organization, and the referendum showed that 358 members were 
opposed to perpetuating the practice, while 201 were of the opinion that 
the present system should continue in vogue. The total membership is 
1,928, and inasmuch as the by-laws require that fifty per cent of the 
members must engage in a referendum in order to insure its validity 
the vote was far from being decisive. 

That the conduct of confinement in case of triplets is not always 
pecuniarily remunerative was demonstrated recently in New York 
City. Some time ago a grocer in the Borough of Queens engaged the 
services of a physician to deliver his wife. The stipulated fee was 
eighteen dollars, but after discovering that the procedure contem- 
plated dealing with triplets, the physician increased the charge to $50, 
which the grocer refused to pay. Litigation ensued in the Jamaica 
Municipal Court, and the jury decided against the plaintiff, notwith- 
standing the fact that the case required the services of two extra 
medical assistants. 

Because of the utter disr^^rd which quacks and venders of nos- 
trums evidenced for the law pertaining to the practice of medicine, 
Judge Green, of New York City, has evolved the following clear and 
simple definition : "The practice of medicine is the exercise or per- 
formance of any act, by or through the use of any thing or matter, or 
by things done, given, or applied, whether with or without the use of 
drugs or medicine, and whether with or without fee therefor, by a 
person holding himself or herself out as able to cure disease, with a 
view to relieve, heal, or cure, and having for its object the prevention, 
healing, remedying, cure, or alleviation of disease." 



288 RECENT LITERATURE. 

The San Francisco catastrophe rendered necessary the convening 
of a special session of the California legislature, during the deliberations 
of which enactments of interest to the medical profession were passed 
which contemplate the following appropriations : The University of 
California receives $83,800, about $8,500 of which is to restore buildings 
and apparatus damaged in the Medical and Veterinary departments; 
the Agnew State Insane Asylum, at San Jose, receives $25,000 for the 
building of temporary quarters for inmates pending the erection of 
permanent buildings ; the State Board of Examiners receives $2,500 for 
the restoration of property; the State Board of Pharmacy receives 
$2,500 for the restoration of property; amounts necessary for the 
reproduction of the reeristers of the State Boards of Examiners in 
Medicine, Pharmacy, and Dentistry; and amounts necessary for the 
issuing of duplicate certificates to physicians, pharmacists, and dentists 
who lost the original papers in the fire. 



RECENT LITERATURE. 



REVIEWS. 



PROGRESSIVE MEDIQNE.* 

Progressive Medicine for March, 1906, comprises the following 
subjects: Surgery of the Head, Neck, and Thorax. Infectious Dis- 
eases — Including Acute Rheumatism, Croupous Pneumonia, and 
Influenza; the Diseases of Children; Rhinology, Laryngology, and 
Otology. There is an index accompaniment. The abstracts are all well 
done, and the compiler's personal opinion, which is frequently given, is 
always of great value. 

♦Lea Brothers & Company, Philadelphia and New York. 



GALL-STONES AND THEIR SURGICAL TREATMENT.* 

The first editiv>n, exhausted in eight months, tells the story of the 
popularity of this work ; it pleases the pri>fession. Sufficient time has 
elapsed since it first appeared for criticism and improvement. The 
result has been a careful revision with added illustrations and explana- 
tory cases, increasing the size of the book about seventy pages. The 
illustrations are fine and the text is plain and well written. It is a good 
boc4c and one is improved by reading it. Few books in medical lit- 
erature merit such praise. c. c. d. 

♦By G. A. Moynihan, M. S. (London), F. R. C. S., Senior Assistant 
Surgeon to Leeds General Infirmary, Leeds, England. Second edition, 
revised and enlarged. Octavo of 458 pages, beautifully illustrated. 
Philadelphia and London. W. B. Saunders & Company, 1905. Cloth, 
$5.00 net ; Half Morocco, $6.00 net. 



A PROFESSIONAL MEDICAL JOURNAL. 



VOLUME XXVIII. JULY, 1906. NUMBER VII. 



ORIGINAL ARTICLES. 



MEMOIRS. 

RURAL CITY MILK SUPPLIES AND THEIR RELATION TO 

INFANT FEEDING. HOME MODIFICATION VERSUS 

LABORATORY MODIFICATION.* 

ANNA MARION COOK, M. D. 

AND 

DAVID MURRAY COWIE, M. D. 

[from the DBPARTUBNT of PBDIATRICS, university of MICHIGAN.] 

Excepting the good that may come from frequent repetition of 
already known facts, thus aiding the dissemination of the knowledge 
of modern infant feeding, it would seem that there is little excuse for 
an article having the above title. When, on the other hand, we compare 
the analysis of milk made in various countries and various parts of 
our own country, note the variety of results obtained, the analyses upon 
which are based the many formulae that have been introduced in text- 
books, and endeavor with failure to reproduce results vouched for 
by standard methods of obtaining definite fat percentages for home 
feeding, it would Seem that some value may be attached to any investi- 
gation that will help to clear up some of these discrepancies. 

RURAL CITY MILK SUPPLIES. 

Towns of 10,000 to 20,000 population, proportionate to their size, 
receive their milk from a radius of twenty, thirty, forty and often fifty 
miles. As distance is time, and time and handling are bacterial growth, 
it is not difficult to see how conditions that obtain in small towns are 
superior to those in the larger cities. It is a well-known fact that the 
so-called good creams of large cities are usually several days old. 
Conditions are better with certified milk. Seldom in rural districts 
is cream delivered over twenty-four hours old. 

The writers are indebted to the Ann Arbor Board of Health for 

*Read before the Section on Medicine at the Jackson meeting of the Michigan 
State Medical Society. 



290 ORIGINAL ARTICLES 

supplying them with samples of milk from the various dairy farms 
which supply the city, and we take this opportunity to thank Doctor 
Wessinger, the health officer, for much useful information furnished 
us at an expense of his valuable time. The milk was brought to the 
milk laboratory in serial number. The name of the dairy was withheld. 
It was collected by an officer at an unexpected time, of his own choos- 
ing. Except where otherwise stated the milk was bottled at the dairy 
and not taken from the tanks in the milk wagon. 

TABLE A. 





PER CENT 








PER CENT 






DAIRY 


FAT IN 


SPECIFIC 


TOTAL 


DAIRY 


FAT IN 


SPECIFIC 


TOTAL 


NO. 


GRAVITY 


ACIDITY 


NO. 


GRAVITY 


ACIDITY 




WHOLE MILK 








WHOLE MILK 






I 


4.1 


1032 


26 


25 


5.5 


1030 


25 


2 


4.2 


1038 


28 


26 


4.0 


IO3I 


28 


3 


4.1 


1032 


24 


29 


3.8 


1032 


24 


4 


4.0 


1030 


26 


30 


3.6 


1030 




5 


3.3 


IO3I 


26 


31 


3.8 


1032 




6 


4.2 


1034 


28 


32 


4.2 


1032 




7 


3.6 


1032 


25 


33 


6.3 


1026 




8 


3.8 


1032 


30 


34 


3.2 


1034 




9 


4.0 


1032 


26 


35 


5.0 


1030 




10 


3.0 


1036 


28 


36 


3.0 


1032 




II 


4.8 


1032 


24 


40 


3.8 


1032 


24 


12 


4.0 


1034 


24 


41 


5.6 


1032 


24 


13 


4.0 


1034 


24 


42 


3.2 


1034 


22 


M 


5.2 


1034 


22 


43 


4.2 


1032 


25 


15 


3.6 


1034 


20 


44 


5.2 


1032 


24 


i6 


3.6 


1032 


26 


45 


4.0 


1034 


27 


17 


3.2 


1034 


28 


46 


4.0 


1032 


25 


i8 


4.2 


1034 


30 


47 


5.0 


1032 


25 


19 


3.2 


1036 


24 


48 


4.4 


1034 


25 


20 


34 


1034 


26 


49 


4.4 


«033 


24 


21 


5.5 


IO3I 


26 


50 


3.8 


1032 


24 


22 


5.0 


1032 


25.5 


51 


4.8 


1033 


24 


23 


4.5 


1032 


28 


52 


5.2 


103 1 


26 


24 


4.5 


1033 


29 











The analyses of this series has to do only with the per cent, of fat 
in the whole milk, the specific gravity and the total acidity. We have 
considered standard milk one which has four per cent, fat, a speciiit 
gravity of 1028 to 1033, and a total acidity not higher than 25.^ The 
results of the analyses are as shown in Table A. By reference to this 
table it will be seen that of the forty-nine dairies examined the fat 
percentage was four, or above four in twenty-five, and that in nine of 
these it was five or above ; seven were between three and one-half and 
four ; eight were below three and one-half, and two of these were three 
per cent. One dairy furnished a ten per cent, milk, which was too high 
for good milk and too low for good cream. It was reported as cream 
below standard, and subsequently it was found that the high percentage 
of fat was due to an attempt to deceive the Board of Health, which had 
had trouble with this dairy before. 

The specific gravity varied proportionately with the fat in most 
cases. It is interesting to note that in the milk of herds in which the 



RURAL CITY MILK SUPPLIES. 291 

inspectx)r found mammary and udder disease, the total acidity was 
high, always 28^ or above. Invariably when the acidity was much above 
25 it could be traced to dirty stables, dirty cows, and careless milking 
methods. The trouble has been in the stables and in the milker. It is 
of very little avail that the housekeeper puts the milk in a cool place and 
protects it from all contamination, if from the time it leaves the udder, 
until it reaches the consumer, it has been through a course of dirt col- 
lection from unclean hands, unclean pails, unclean tanks, et cetera. 
This journey through unclean receptacles is too frequently evidenced 
by the visible sediment that greets the eye as the bottom of the con- 
tainer is reached. 

We found through the investigation of the Board of Health, that 
the usual plan of dispensing milk is as follows: All bottled milk is 
taken from the previous evening's milking, and that which is not 
bottled is carried in the faucet tank in the front compartment of the 
wagon. All milk taken from the cows in the morning is put into ordi- 
nary cans. It must be evident to every one that the bottled milk, even 
though it is of the night milking, stands a better chance of reaching the 
consumer in good condition than milk that is put in the faucet tank or 
in ordinary cans. It must be a very difficult task to keep the tanks and 
cans clean, even when the strictest measures of cleanliness are observed. 
How great the chances of contamination when no special thought is 
given to them ! Picture the bacteria that may lurk in the seams of the 
can and the bottom where it is impossible to reach with hand and brush I 

After counseling with the Board of Health we decided that for the 
present, until more elaborate methods can be carried out to prove the 
value of these simple methods, that standard milk must contain four 
per cent, fat, and have an acidity not above 25 per cent, decinormal 
sodium hydroxide solution. We have found that by notification and 
instructions to the dair3mien that the high acid values in the milk have 
been lowered. We find most of the milkmen anxious to cooperate as 
best they can, and a visit to the various dairies in this district demon- 
strated to us that much of the faulty condition was due to their lack 
of knowledge of bacterial growth. The condition in the milk rooms 
was for the most part fairly good, but in the stables no eflForts were put 
forth to secure the cleanliness that is so essential. The amount of good 
that can be accomplished by local boards of health cannot be overesti- 
mated. When the public begin to realize that by far the greater num- 
ber of deaths in infants and young children, rich and poor alike, are 
due to diseases of the digestive organs, and that these are caused by 
impure milk, greater efforts will be put forth to bring about conditions 
that will compel dairymen to have regulation stables and produce 
standard milk. If only common cleanliness could be guaranteed, thous- 
ands of infants' lives* could be saved yearly. Sterilization will not 
accomplish as much as is expected of it. Germs kill not only by invad- 
ing the tissues of the body but also by elaborating chemical poisons in 
the milk, which are unaflFected by either Pasteurization or sterilization. 



292 ORIGINAL ARTICLES. 

We must have clean milk. If health officers were better paid and were 
obliged to qualify for office by competitive examination, before an 
unbiased board, much of the difficulty would be solved. 

Taking all things into consideration the above analyses show that 
the milk supplied to Ann Arbor is on the whole good so far as its fat 
content is concerned. Some of the dairies, particularly numbers one 
and six, we have examined at various times for two or three years and 
have never found the fat per cent, below four. They have frequently 
been dirty, and at these times their acidities have been high. The 
dairies around Ann Arbor represent the prevailing type. They are 
probably no better and no worse than those in other districts. The 
milk that is being delivered is physically good, is seldom skimmed or 
diluted. LxDwered fat percentages can usually be traced to improper 
and poor feeding, in but few instances to diluting. 

MILK ANALYSIS. 

Practical milk analysis resolves itself into the estimation of but a 
few points. Without these no milk modification can be correct. The 
possession of more minute data will help us but very little. Even 
methods that are thought to be most ideal are only approximate. We 
have, then, to estimate the per cent, of fat in the whole milk and in the 
cream, the specific gravity, and if we would have the alkalinity correct, 
the total acidity should be known. However, for practical purposes 
this is not necessary, and the total acid value may be employed as a 
means of gaining some idea of the cleanliness of the product used. 

Fat estimation requires about ten minutes time. The most reliable 
test is the Babcock test. Small hand-turning testers are manufactured 
by various creamery manufacturing companies. A whole outfit can be 
bought for a comparatively small sum, including directions which are 
too familiar to you all to require repetition here. All fat estimations 
reported in this paper were made with a large electric centrifuge. 

The approximate percentage of proteids is estimated by comparison 
of specific gravity with fat per cent. The proteids of milk are fairly 
constant, more constant than the fat. They are estimated at four per 
cent. If the specific gravity is low and the fat per cent, high, the pro- 
teids are normal. If the fat per cent, is normal or high and the specific 
gravity high, the proteids are increased. If the fat per cent, is normal 
or low and the specific gravity is low, the per cent, of proteids is 
decreased. It is more necessary to be in possession of definite percent- 
ages of fat than of proteid. The symptoms of excess of proteid are much 
more evident than are those of excess of fat. The stools may be used as 
an index of proteid digestion, yet it must be remembered that infants 
may thrive and manifest no complaints and still show curds in the 
stools. This symptom alone does not necessarily mean that the casein 
must be decreased. It must be combined with other phenomena which 
go to make up the symptom complex of proteid indigestion. 

Sugar in cow's milk for practical purposes may be considered as a 
constant factor varying little from six per cent. The polariscopic 



RURAL CITY MILK SUPPLIES. 293 

method for sugar estimation is the most practical and is very accurate. 

Knowing the percentage of fat in the whole nulk and in the cream, 
it is a very simple matter to calculate the quantity necessary to give 
the required amounts. We find Baner's^ method of great practical 
value. It is simple and gives fairly accurate results. We think as 
accurate results can be obtained by home modification with this method 
as are usually obtained by Walker-Gordon Laboratories, and it is much 
better from the standpoint of independence as there is no patent upon it. 

Percentage feeding resolves itself into so simple an algebraic 
expression that any one mathematically inclined can devise equations 
of his own, if he cares to. Those who do not wish to spend time work- 
ing out equations of their own can accept this method and have the 
assurance that they will obtain good results. Possibly its only point 
of failure is in the calculation of low proteid percentages, but this 
applies only when low per cent, top milk fat is employed. The method 
is as follows : 

BANER'S METHOD. 
Let Q represent the quantity of mixture required for twenty-four hours. 
F represent the desired per cent, of fat. 
P represent the desired per cent, of proteid. 
S% represent the desired per cent, of sugar. 
A represent the desired per cent, of limewater. 

C = Cream, M = Milk, W = Water, LW = Limewater, S = Sugar. 
It will be found that 
Q 



% of fat in cream — 4 
QXP 



X (F — P) = Cream in ounces. 
— C = Milk in ounces. 

X Q = Limewater in ounces. 



100 
Q — (C -f M + LW) = Water in ounces. 



= Sugar in ounces. 



(S% - P) X Q 
100 

Example: A mixture of forty-eight ounces containing three per 
cent fat, one and five-tenths per cent, proteid, six per cent, sugar, and 
five per cent, limewater is desired. The whole milk is known to con- 
tain four per cent, fat, and the cream, upper four ounces, after standing 
four hours, sixteen per cent. fat. 

C = — z^ X (3 — 1.5) = 6 ounces. 

16 — 4 ^ ' 

M = ^^ ^ ''^ — C =12 ounces. 

4 

LW = ^35- X Q =2.4 ounces. 

W = 48 — (6 4- 12 4- 2.4) = 27.6 ounces. 
S^ (6-..S)X48 

100 



SM 



ORIGINAL ARTICLES. 



These equations assume that the whole milk contains four per cent, 
fat and four per cent proteid. In order to use the formulae with exact 
results we must substitute the actual per cent, of fat in both cream and 
whole milk. For instance, if milk tests 4.5 or five per cent fat the 
cream will test about eighteen per cent, fat (Table D). After having 
run a number of tests we are satisfied that most milk containing four 
per cent, fat will not show greater than sixteen per cent, fat in Ae 
upper four ounces of cream. 

The following cases illustrate how near the desired amount of fat is 
obtained by the equations. table B. 

HOSPITAL MODI pic A TIONS, 
BABY F. 













LIME- 


FAT PER CENT 






FAT 


SUGAR 


PROTEID 






DATE 


QUAWTITY 


PER CENT 


PER CENT 


PER CENT 


WATER 
PER CENT 


IN 
MODIFICATION 


4-1-06 


18 OZ 


2 


6 


0.5 


5 


2. 


4-2-06 


«« 










1-9 


4-3-06 


M 










2.1 


4-4-06 












2. 


4-5-06 


M 










2. 


4-6-06 


f« 










1.6 


4-7-06 


M 










2.2 


4-8-06 


« 










2. 


4-9-06 


M 










2.1 


4-10-06 


«4 










2. 


4-1 1-06 


22.5 OZ. 










2. 


4-12-06 


<« 


2 


6 


1 (whey) 


5 


2. 


4-13-06 


M 










2. 

Average 1.99 



BABY McD. 



5-8-06 


48 OZ. 


2.5 


6 


0.5 


I 


2.5 


5-9-06 




2.5 


6 


0.5 


I 


2.5 


5-10-06 




2.5 


6 


0.5 


I 


2.4 
Averacre 2.46 



BABY K. 



5-8-06 


18 OZ. 


2 


6 


0.5 


5 


2. 


5-9-06 


M 


2 


6 


0.5 


5 


1.8 


5-10-06 


M 


2 


6 


0.5 


5 


2. 
Average 1.93 



BABY A. 



5-16-06 


36 OZ. 


2 


6 


0.5 




2. 


5-19-06 


48 OZ. 


3 


6 


I.O 




3. 


5-20-06 


56 OZ. 


3 


6 


I.O 




2.6 


5-21-06 


M 


3 


6 


1.0 




2.8 


5-24-06 


•4 


3 


6 


I.O 




3. 


5-27-06 


«« 


3 


6 


I.O 




2.8 


5-2&-06 


II 


3 


6 


I.O 




2.6 


5-29-06 




3 


6 


I.O 




3.0 



HOME MODIFICATIONS, 



5-1 1-06 
5-1 1-06 


Mrs. S. 
Mrs. B. 


2 
2 


6 
6 


0.5 
I.O 


5 
5 


2. 
1.9 



RURAL CITY MILK SUPPLIES. 



296 



An eighteen ounce mixture, of two per cent, fat, one-half per cent, 
proteid, six per cent, sugar, five per cent, limewater was required. The 
modification (Baby F) was made according to the equation given. The 
modified milk was then tested for its fat per cent., with the result that 
in thirteen days the average fat was 1.99 per cent. We could hardly 
look for more accurate results than these. Our method of separating 
the upper four ounces was one that every busy mother would probably 
use. We simply poured oif the top milk or cream, our object being to 
test a home method of modification that would be within the range of 
ability of any household. We find that the percentage of fat by this 
method does not diifer from that obtained by use of the siphon. 









TABLE C. 








PER CENT 


PER CENT OF DISTANCE OF CREAM LEVEL FROM THE TOP TO THE 




OF FAT 


BOTTOM 


OF A STANDARD QUART BOTTLE AFTER STANDING 


NO. 


IN 
WHOLE 




















MILK 


4 HOURS 


5 HOURS 


6 HOURS 


7 HOURS 


8 HOURS 


I 


4.2 


33 










2 


4.5 


33.3 










3 


4.2 


35.0 










4 


4.8 


34.8 










5 


5-0 








39 




6 


4.6 


34-3 










7 


4.6 


36.3 










8 


3.9 


31.2 










9 


3.7 


28.1 










10 


6.2 










39.1 


II 


5.0 


40.6 


40.6 


40.6 






12 


4.2 


32.3 


33.0 


33.0 






13 


4.2 


29.7 










M 


5.1 


36.0 




s 






15 


5.0 


37.5 










16 


4.9 


28.1 










17 


4.8 


34.4 










18 


5.0 


40.6 











The average cream depth of those milks approximating 4^ fat is a little less than 
a third of the distance from the top to the bottom of the bottle. Those approximating 
5% a little over a third of the distance (36.9% ). 

The percentage of fat in the whole milk of herds will necessarily 
vary with the conditions existing at different times of the year, and 
while it is not necessary to make daily fat estimations they should be 
made at more or less frequent intervals, particularly if the infant shows 
signs of digestive derangement. 

We have made a few observations on the depth of the cream layer, 
after standing four hours (Table C), with relation to the fat content of 
the whole milk. A regulation quart bottle, allowed to stand four hours, 
after being thoroughly mixed, will show a more or less definite fat per 
cent when the cream layer is a certain depth. When the depth was 
thirty-three and one-third of the bottle depth the per cent, of the fat in 
the whole milk averaged about four ; when the cream depth was thirty- 
five to thirty-seven per cent, of the bottle depth, the fat per cent, aver- 



296 



ORIGINAL ARTICLES. 



aged five. This, too, can be used with fairly accurate results in home 
modification. 

To vary the percentage of fat, it is necessary to use diflFerent layers 
of the miyc. When the upper four ounces contain approximately six- 
teen per cent, fat, the second four ounces will yield six per cent, fat, the 
third four ounces four per cent, fat and the fourth four ounces three per 
cent, fat, so that by simply pouring oflf the top in definite amounts 
almost any desired per cent, of fat content may be obtained. By using 
the upper eight, twelve or sixteen ounces, we may get fat per cents, of 
approximately twelve, ten, and seven per cent., which are somewhat 
lower than the percentages claimed by Holt. 

TABLE D. 







AFTER STANDING FOUR HOURS THE FAT PER CENT IN THE 


EXPER. 


FAT IN 
WHOLE MILK 




NUMBER 


UPPER 4 


SECOND 4 


THIRD 4 


FOURTH 4 






OUNCES • 


OUNCES 


OUNCES 


OUNCES 


I 


4.2 


16.8 








2 


4-5 


16.2 








3 


4-2 


14.4 








4 


4.8 


14.4 








5 


5.9 


17.0 








6 


4-6 


14.2 








7 


4.6 • 


15.5 








8 


4.9 


14.0 








9 


3.7 


13.6 








10 


5.0 


18.0 


6.6 


4.6 


4.4 


II 


4.8 


17.2 


6.0 


2.0 


1.8 


12 


5.0 


18.4 


6.4 


3.0 


2.4 


' 13 


4.6 


17.2 


5.4 


3.4 


1.6 


M 


4.8 


17.6 


6.4 


4.4 


2.6 


15 


4.0 


16.0 


5.8 


3.4 


3.0 


i6 


4.0 


16.0 


5.8 


4.0 


3-2 


17 


3.8 


15.4 


5.2 


3.8 


3.4 



There are a good many reasons why gravity cream is better than 
centrifugal cream, for milk modifications. There may be something in 
the objection that in centrifugal cream the natural emulsion is par- 
tially destroyed, but there is considerable diflFerence of opinion upon 
this point. We think that the arguments in favor of gravity cream are 
that it is usually fresher and the percentage of fat more constant than 
in the centrifugal cream distributed in this section. If creams of 
definite percentages were placed on the market, we can see that a great 
advantage would be secured. There seems to be no eflFort in this direc- 
tion in the smaller towns and unless the fat per cent, in cream is esti- 
mated very frequently, disordered digestion will surely arise. 

Our method of removing different layers of top milk after it has 
stood a certain length of time, and thus procuring more or less definite 
fat percentages, seems to us to be far more satisfactory. Holt and 
others following in his lead, have given examples of top milk feeding 
and have reported their results of analyses of the diflFerent layers of 
top milk. We have repeated their experiments (Table D) and have 



RURAL CITY MILK SUPPLIES. 297 

been unable to produce the results obtained by them. Our conditions 
were probably different. We sought to have them the same as in the 
home, where the modifying is most often done. A milk that is set 
immediately after milking will, after four hours, raise a higher per cent, 
of fat in the cream than milk that has stood for a time, then mixed and 
reset for four hours. The latter are the conditions that must neces- 
sarily exist in the home, when milk is obtained from a milkman some 
hours after milking, the time of the milking and the amount of jolting 
unknown. It may be for this reason that our results differ from those 
of other investigators. At no time were we able to obtain twenty per 
cent, fat in the upper four ounces of a quart of milk. The highest we 
encountered was eighteen and four-tenths per cent. Usually an aver- 
age of sixteen per cent, was obtained. Even with five per cent, whole 
milk twenty per cent, cream could not be obtained by four or six hours 
setting. 

From our investigations we can say that a milk, after being thor- 
oughly mixed by pouring from one vessel to another and set in a stand- 
ard quart bottle, will yield in the upper four ounces approximately 
sixteen per cent, fat instead of twenty per cent., as is claimed by Holt 
and others. 

THE PROTEIDS OF COWS MILK. 

The proteids of cow's milk differ from those of woman's milk in 
that the percentage of casein is greater and that of soluble albumin less. 
It is the casein that gives us the greatest trouble in infant feeding. It 
was never intended that the human animal should consume large 
amounts of casein. It would seem then that any method of milk modi- 
fication that has as its object the elimination of excess of casein, must 
be the most ideal. So far as we know the proteids that remain in cow's 
miik after the casein has been removed, are identical with those of 
woman's milk. They are at any rate soluble albumins and require much 
less digestive work than do the insoluble or solid milk bodies. If, then, 
. we wish to feed an infant soluble albumin, in quantities sufficient to 
equal the proteid content of mother's milk, it is evident that the use of 
whey alone which contains but 1.17 per cent, proteid will not accom- 
plish this. To increase the content we should have to evaporate the 
whey, that is, if we evaporate the water of twenty ounces until it is 
reduced to ten ounces we will have a whey containing twice the amount 
of proteid of the twenty ounces, or 2.34 per cent, proteid. This is 
hardly practical for home modification because of increased timie 
required in the preparation, which is in reality the only objection raised 
by mothers against modified milk. During the first two months of 
life is the time when an infant most needs soluble albumin or milk that 
closely resembles mother's milk. We do not care to raise our proteid 
content during this period above one per cent. 

It would seem that our argument does not hold, when our constant 
aim has been to modify the milk of the cow to as nearly a counterpart 
of mother's milk as possible, for it is a well-known fact that throughout 



296 ORIGINAL ARTICLES. 

the lacteal period mother's milk never contains less than two per cent, 
proteid. But we must bear in mind constantly that cow's milk can 
nerer be exactly like mother's milk, and practical experience has dem- 
onstrated to us that infants thrive on whey modifications and develop 
bone. 

Nothing definite has been worked out with regard to the exact modi- 
fication of the salts. These are reduced by dilution as are the proteids. 
Experiment has shown, however, that very little of the salts are lost in 
the making of whey, so that by the use of whey in our modifications 
instead of water as a diluent we increase rather than decrease our salt 
per cent. 

Qinical experience has taught us that infants fed on modified milk 
do better proportionately as the amount of casein or solid food is gradu- 
ally increased. It may be necessary to begin with simple whey, a 
method that has proven very satisfactory, where the child is never 
nursed by the mother. To feed an infant for any considerable length 
of time on a purely soluble albumin diet or low casein diet might easily 
lead to serious consequences. 

To prepare soluble cUbumin or whey the casein is removed most 
conveniently by the use of commercial junket 'tablet. One tablet dis- 
solved in a little water, added to a quart of skimmed milk, which has 
previously been heated to 98*" Fahrenheit will yield from thirteen to 
fourteen ounces of whey in fifteen minutes time. The casein separates 
as a greenish-yellow, semiopaque fluid. In separating the curds from 
the whey pressure should be avoided. We found a single layer of 
absorbent cotton worked rapidly and effectually as a filter. 

The mother must be especially instructed in regard to the use of the 
junket tablet as the directions on the box are not for making simple 
whey. Trouble arises if squeezing is employed, as casein passes through 
and the whey will have a milky look. 

It must fce remembered that rennet works rapidly, and like other 
ferments there is little limit to the duration of its action. It is still 
actively present in the whey and if it comes in contact with the casein, 
as the casein of the cream in a milk modification, it mil rapidly convert 
it into curds. Hence the necessity of bringing the whey to a tempera- 
ture of 150'' Fahrenheit before adding the cream. This requires but a 
few moments time, 

HOME MODIFICATION VEHSUS LABORATORY MODIFICATION. 

We now come to the consideration of the accuracy of percentage 
milk modifications, modifications produced at milk laboratories, and 
those produced in the hospitals and in the home. We will consider 
only fat percentages, as fat is the most variable constituent of cow's 
milk, and the one that concerns us most in infant feeding. It is gener- 
ally believed that percentage milk feeding and the term "modified milk" 
originated with those who were the instigators of the laboratory idea. 
It will be of interest to many of you to know that percentage feeding 



RURAL CITY MILk SUPPLIES. 299 

was not only worked out some time before the formation of the Walker- 
Gordon Company, but the ideas were given to the profession in book 
form by Doctor William Henry Cummings, of Williamstown, Mass- 
achusetts, in 1859, in a little book entitled "Food for Babes; or, Arti- 
ficial Human Milk and Manner of Preparing and Administering It to 
Young Children." If any of you have access to this interesting little 
work by Doctor Cummings and will turn to page 58, you will find that 
he says : "The milk adapted for the newborn calf is not suitable for an 
infant. It must be modified or else it will do harm rather than good." 
He goes on to state that "there is too much cheese in cow's milk and 
the child cannot digest it." He then accurately works out the yearly 
needs of a child in pounds of butter, proteid and sugar, which he esti- 
mates at twenty-five, seventeen, and ninety respectively for a year's 
feeding for an average child. Then he proves the inadequacy of cow's 
milk as a substitute, showing that in the same quantity of milk a child 
would get but sixteen and one-half pounds of fat in a year's feeding, 
but a great increase in the casein. He further gives specific dilutions 
for various ages suiting the modification to the changes incident to 
development in the child. 

It is said that Liebig had it so arranged that his prescriptions for 
infants' food, which consisted in the addition of maltose to cow's milk, 
were filled at an ordinary pharmacy and that other physicians patron- 
ized these places. Liebig's object was to bring about conditions that 
exist in woman's milk. This is another evidence of the adage, "There 
is nothing new under the sun," and would seem to detract from the 
claim of the laboratory people that they were the originators of the 
per<;entage method of feeding. However, as they have popularized 
this method they are entitled to the honor that should come from its 
general adoption. 

Milk laboratories claim for their product accurate percentages and 
clean milk. It is upon these claims that their success depends. There 
has been some dissatisfaction with laboratory milk both on the part of 
the profession and the laity. We think that Doctor Morse* is justified 
when he says that "much of the criticism has come from physicians 
who have failed to appreciate the purpose and capabilities of the labo- 
ratory ; that some physicians seem to have found the laboratory a con- 
venient scapegoat to account for the lack of development of certain 
babies, fed on laboratory milk prepared according to their own direc- 
tions." "It has been much easier and more condusive to their self- 
respect to attribute the failure to the laboratories rather than to their 
own imperfect methods of prescribing," and that "the laity are inclined 
to exaggerate every mistake made by the laboratory and minimize their 
own." 

However, knowing much of the above to be true, we cannot help 
being impressed with certain facts that confront us. We must stand 
with those who give obeisance to the sentiment, "to the law and to the 
testimony." Does the Walker-Gordon Company live up to its claims? 



300 



ORIGINAL ARTICLES. 



By reference to Doctor Wentworth's* series of analyses of laboratory 
milk modification (Table E), part of which we incorporate below, it 
will be seen that frequently inaccurate products are dispensed. Out of 
twenty-six different samples only two gave the percentage of fat pre- 
scribed (numbers nine and sixteen). One gave one per cent, too little 
fat (number twenty-two). In fifteen of those analyzed too little fat was 
found, an error of one-half per cent, or more in each case. This 
impresses us as a difference too great for a company making such 
claims, especially as with but two exceptions the error was a lowering 
of the fat content. These experiments were made four years ago, but 

TABLE E. 
ADAPTED FROM DOCTOR WENTWORTITS REPORT, 









< a H 
^ u z 


FORMULA 






< d H 

-} bd 2 


FORMULA 








:3 Ctf M 








3 « M 










S M U 


SUPPLIED 






S M U 


SUPPLIED. 








Oi Q ^ 








« Q at 










p fl« £ 


PER CENT. 






otf u 


PER CENT. 








u, £ 








to. £ 




NO. 


DATE 


FAT. 


FAT. 


NO. 


DATE 


FAT. 


FAT. 


I 


Dec 


i8, 1901 


4. 


4.2 


M 


Jan. 3, 1902 


3 


2.2 


2 


*< 


I9f 1901 


3.5 


2.5 


15 


" 7. 1902 


3. 


2.6 


3 


** 


19. 1901 


3. 


2.6 


16 


" 9, 1902 


1 




I. 


4 


« 


20, 1901 


4. 


3.5 


17 


" 15. 1902 


3 




2.4 


5 


M 


20, 1 90 1 


3-5 


3.2 


18 


" 23, 1902 


3 




2.3 


6 


" 


21, 1901 


1.5 


1.6 


19 


" 24. 1902 


3 




2.3 


7 


<« 


21, 1901 


4. 


3.6 


20 


" 27. 1902 


4 




3.3 


8 


« 


23, 1901 


3.5 


2.8 


21 


" 29. 1902 


2 




1-3 


9 


« 


24. 1901 


3.5 


35 


22 


Feb. 28, 1902 


4 




3. 


10 


ft 


24, 1901 


4. 


4.2 


23 


Mch. 7, 1902 


3 


5 


2. 


II 


** 


25. 1901 


4. 


3.4 


24 


" 15, 1902 


4 




3.1 


12 


M 


26, 190 1 


3.5 


3.2 


25 


" 18, 1902 


4 




3.4 


13 


« 


30, 1 90 1 


4. 


3.4 


26 


*' 24, 1902 


4 




31 



there ought not to be any reason to believe that conditions at the pres- 
ent time are any better than they were then. The argument used 
against the commercial baby foods is that they do not furnish proper 
amounts of fat, and this series of analyses seems to show that the lab- 
oratory milk is in reality little better. 

The question naturally arises, Where is the fault? We have no 
reason to think that the company's intentions are not good. In its 
infancy, and of late years, it has delivered milk with exact prescribed 
percentages. It is not at all improbable that success has brought to it, 
as to many other prosperous business concerns, a feeling of self-secur- 
ity, protected, too, by its patent, and consequently carelessness has crept 
in, particularly on the part of the employees. One of us visited the prin- 
cipal Walker-Gordon laboratory in Boston last summer, in company 
with a lay friend. The laboratory is pictured as perfect in its appoint- 
ments and immaculate in its cleanliness. What greeted the eye, how- 
ever, was not even the cleanliness of a down-town butcher shop, nor 
could we be impressed that it was sterilized uncleanliness. The man at 



RURAL CITY MILK SUPPLIES. 301 

the rack was juggling prescriptions, it seemed to us at the rate of fifty 
per minute. Occasionally a little milk slopped over. It did not seem to 
us that the care of a drugstore prescription clerk was g^ven to the com- 
bining of the various constituents of the milk modifications. A visit, 
the same day to the Floating Hospital showed an entirely different state 
of affairs. There home modifications were being prepared by the phy- 
sicians, nurses and mothers. Cleanliness was paramount, even though 
their quarters were much crowded. 

The Walker-Gordon Company had difficulty in obtaining a patent 
on percentage milk modification. It is generally known that it was 
owing to Doctor Rotch's influence that it was finally obtained. In a 
letter presented to the patent office at Washington by the Walker- 
Gordon Company, Doctor Rotch says : "It js of the greatest importance 
to physicians that this process should be protected in every way as it 
is a question of many babies' lives being saved by it in the future. 
Unless protected and under careful supervision great harm may be 
done by the misuse of this new instrument of precision which you have 
placed in our hands and which the physicians of the future will surely 
thank you for." Doctor Rotch, the instigator of the laboratory idea, 
has no financial interest in the concern. He has simply been a zealous 
promoter of what ought to be an ideal system, and has worked unsel- 
fishly. 

The patent was granted, a peculiar patent, which cut off competi- 
tion, the most wholesome stimulant for the production of superior 
articles. It is indeed fortunate that there can be no patent to prevent 
one from carrying out similar operations in the home. Our experiments 
with home modifications, by nurses and mothers, show that the results 
obtained are generally more accurate than laboratory modifications, at 
least so far as the fat content is concerned. The large bulk of the 
population is scattered through the rural districts. They do not need 
Walker-Gordon laboratories, but they must have clean and uninfected 
milk. The medical profession and enlightened mothers can arrange the 
rest ; patents are unnecessary. It would be hard to improve upon the 
Walker-Gordon milk as it is received from their farms. The conditions 
at the farms are said to be excellent. The cows are well chosen and 
their feed carefully regulated. All the cows have been tested with the 
tuberculin test. This is a great advantage over the ordinary herd milk 
as delivered in towns. It is a question whether this high grade milk 
may not more than compensate for the differences in the percentages 
of the modified milk. There may be some good reasons for such a 
patent but we fail to see the benefits to the public, to the babies, for 
whose benefit the patent was granted. Other concerns of great magni- 
tude have prospered, as the Mellin's Food Company, without patents 
or copyrights. We think that the patent was unnecessary and has been 
the means of retarding the furtherance of what might be a great boon 
to bottle-fed babies if properly controlled. 

The laboratory idea is a good one, but equally good if not better 



302 ORIGINAL ARTICLES. 

results will be obtained in the rural districts by intelligent home modi- 
fication. It will doubtless be only a matter of a few years before the 
state of Michigan, through the efforts of the State Society, which rep- 
resents the professicHi of the state, will require that all cows used for 
dairy purposes shall be proved to be free from tuberculous infection by 
means of the tuberculin reaction. Under present conditions we think 
that the dairymen are in a sense justified in objecting to the test. This 
objection is of course purely commercial They cannot appreciate why 
they should lose the value of a cow or part of a herd because a tuber- 
culin reaction has been obtained. It would seem only just that the 
state furnish cows of standard breeding to replace the diseased cows. 
There is no other article of food that is more generally used than milk 
and the various food products manufactured from milk. 

There are very few infants that cannot be fed on modified cow's 
milk if the principles of milk modification are thoroughly comprehended 
by the physician. The question of the superiority of one sugar or one 
alkali over another is a subject worthy of much attention, but for lack 
of time cannot be discussed here. 

^In the estimation of the total acidity no account was taken of the CO3 content. 
The figures accordingly are only approximate. 

'Baner: New York Medical Journal^ Volume LXVIl, 1898, page 345. 
'Morse: Journal^ of the Michigan State Medical Society^ 1905. 
*Wentworth: Boston Medical and Surgical Journal^ 1902. 
A. M. C, Ntw England Hoi^itnl, Rtxhury, Matfckntettt, 

D. M. C, Univtrtity 0/ Michigan, Ann Arbor, 



LESSONS IN LONGEVITY. 

JOHN S. CAULKINS, M. D. 
SECOND PAPER, 

The questions formulated in the opening paper on this subject 
were: 

Is it desirable to attain the age of eighty-three years? 

If so, how is that objective point to be reached? 

Only the first query was considered in that discussion. The second 
will now receive attention. 

The conclusion arrived at, with regard to the first point, was that 
whether seen from the personal or sociologic side no generalization 
could be made, circumstances varying so widely that every case would 
have to stand on its own merits and be determined by its own surround- 
ings. These are so different that no general rule can be applied. Every 
very aged person is in a class by himself. One may find life desirable 
until late into its evening, while his much younger neighbor may find it 
intolerable. 

Reference having been made in the former paper to Osier's grim 
pleasantry about a deadline for all at sixty, the logical conclusion was 
drawn that the practice would not apply as a general rule, since much, 
or at least some, good work has been done by older heads and hands 



LESSONS IN LONGEVITY. 303 

than are contemplated by the three-score mark, and its adoption would 
consequently reduce working years down to twenty, Osier's dictum 
being that a man is physically ripe at twenty, mentally at thirty, and 
morally (if ever) at forty, leaving, after being ripened all around, only 
twenty years for work. Since the product of the fully ripened man is 
all that is really and truly valuable, everything else being deficient and 
immature, the time limit is too short for finishing anything calculated 
to benefit mankind in the way of upward development. Give us forty 
years for study and work instead of twenty and one after another the 
evils that now infest human society will disappear. They are all caused 
by ignorance. They are disease, crime, poverty, war, and every other 
noxious thing that can be named as the result of ignorance, or you 
may call it imperfect knowledge. What is wanted is study — ^more time 
for study to learn their causes and. how to avoid and remedy them. We 
are thus led to the conclusion that if we cannot affirm longevity to be 
a blessing in each individual case we can affirm it in the general case : 
that the way to improve mankind is to lengthen the span of human 
life. The conviction cannot be resisted that herein lies Ae remedy for 
the evils which beset us from the cradle to the grave. More time is 
wanted — ^more time to investigate the causes of these evils and more 
time to study their remedies. There is no alternative, and the fact always 
has been more or less imperfectly felt. This is why poets and prophets 
in all ages have inculcated reverence for old age. They clearly saw 
that it was the old upon whom the young must depend for help. 
Examples of filial piety have consequently been with them a favorite 
theme, like Eneas carrying oflf his father from burning Troy on his 
. shoulders. "Honor thy father and mother," says the decalogue, "that 
thy days may be long in the land that the Lord thy God giveth thee." 
There is involved in this injunction much more than a mere sentiment 
of respect for progenitors. It involves doing as well as feeling — doing 
all that can be done for the comfort and well-being of the aged, 
thereby prolonging their time and the opportunity to work for the 
good of coming generations. 

The field for this work is wide, we might say interminable, and 
needs age as well as youth for its exploitation. When the end of the 
path, as now known, is reached, it is for youthful vigor and enthusiasm 
to push on and find new paths, but youth cannot give undivided atten- 
tion to work alone, it must stop and sow its wild oats and wait for the 
crop to be harvested before knowing the value of its own discoveries. 
Time is needed and the serenity of mind that age alone can bring, to 
separate the true in them from the apparently true and to digest and 
assimilate the new truth. When Osier said that the world would miss 
very little of real value if his sixty-year limit were enforced, his bolt 
flew widely from the mark. To show how widely, let us mention a 
few names out of the long list of the old who have done work that 
the world would miss, beginning with our own country and time. 

Doctor Oliver Wendell Holmes. — Not claiming that what was 



304 ORIGINAL ARTICLES. 

done by Holmes belongs to the highest class of work, it is safe to say 
that it is the best of the class to which it belongs, and who would like 
to miss that delightful compound of fun, wit, and wisdom that he has 
left us. Ask William Osier this question and we may be sure he will 
say — **Not I for one. Here is really an exception to my general rule." 
We must remember that Holmes was past eighty when he wrote his 
last book, or as he himself put it, he was "eighty years young." 

Doctor Willard Parker is another name to be mentioned among 
our contemporaries. He was born in 1800 and died in 1884. Like 
Holmes, he was active to the last — b, famous surgeon, original in 
methods, skillful in practice, a fluent writer and a good teacher. He 
was a philanthropist, too, and, for several of his later years, president 
of the New York State Home for Inebriates. His observations and 
discoveries in surgery are of lasting and real value, and the world 
would have missed something if he had died twenty-four years sooner. 

The above are two names out of a long list that could be made 
from among our contemporaries who have worked hard after they had 
passed the four-score stake, but time will not permit. However, we 
will mention another. 

RussKLL Sage, the old New York banker and millionaire, is now 
eighty-seven past and as sharp in chasing the dollar as the youngest 
in the race. Whether he will be missed is a problem. Likely he will, 
hut whether his confreres will view his departure with pleasure or 
regret we are unable to say. 

Joseph Henry died in 1878 in his eighty-second year, being secre- 
tary and director of the Smithsonian Institute, president of the Amer- 
ican Academy of Sciences and of the Philosophical Society, director 
of the Coast Survey, and in the actual discharge of all his duties 
until the very last, besides carrying on his own original researches in 
physics which place him in the front rank of the great physicists of the 
world. 

Edward Everett Hale is conspicuous among our old who are still 
alive. He is the author of "The Man Without a Country," a book very 
much read and admired forty years ago. His latest book, "Recollec- 
tions of One Hundred Years," shows no decline in mental vigor. It 
is a chatty and very readable discussion of the events of the last cen- 
tury, as good as any of the more than forty books of which he is the 
author, but leaning rather too much to suit me towards the federal 
side of our early politics. He is at present chaplain to the United 
States Senate. He is one month younger than the man who is reading 
to you. 

Thomas W. Higginson, another Massachusetts scholar and author 
of a great many books, is a year younnger than Hale, and is as busy 
and active. His present incumbency is historian for the State of 
Massachusetts. 

Francis Parkman, another Boston scholar and author, did not 
reach the advanced age attained by his neighbors above, his life span 



LESSONS IN LONGEVITY. 305 

having been broken when it reached a little beyond the three-score-and- 
ten mark. He was a sickly man, with very poor eyes, but in spite of 
these physical handicaps his work is of more permanent importance 
than that of any of the above-mentioned, and he and his work can be 
quoted in proof of the assertion which will be made further on, that 
good, hard work, if pursued with lofty motives and love of the work, 
improves rather than impairs the prospect for long life. Parkman's 
work is the history of the long struggle of the French (finally ending 
with the fall of Quebec in 1759) to colonize North America. The 
work is so exhaustive and its style so fascinating that there is nothing 
left for another historian to do. It is safe enough to pronounce its 
twelve volumes to be monumental literature. 

Before taking leave of our contemporaries, let us mention the 
names of three famous women who were very old, and who retained 
their mental equilibrium to the last. These are Lucretia Mott, 
Elizabeth Cady Stanton, and Susan B. Anthony. They were 
reformers, lecturers, and writers, very prominent in the antislavery 
agitation. Mrs. Mott was much older than the other two, and died 
about 1880, at the age of eighty-eight years. Mrs. Stanton died 
recently at the same age. Miss Anthony was still with us at eighty-six 
in the discharge of her official duties at the New York State Industrial 
Home for Inebriates, having received her appointment from Governor 
Flower. It was mainly owing to her exertions that the law was passed 
exempting the woman's earnings from liability for the husband's debts. 
A notable incident in her career is her experience as a voter. She 
believed that the fourteenth and fifteenth amendments gave women the 
right to vote, and she accordingly went every year to election and offered 
her ballot. To get rid of her the board finally concluded to take the 
ballot and then prosecute her for the offense of illegal voting. This 
was done and she was fined one hundred dollars, but no effort was ever 
made to collect the fine. 

There was a fourth woman, more famous in her day than the 
others. She belonged to a family noted for genius and longevity, both 
of which are conspicuous in her hereditary endowment since she 
reached the age of eighty-four, and gave to literature a long list of 
books, the second of which has been translated into many foreign 
languages. This woman is Harriet Beecher Stowe. Those whose 
memory cannot revert to the time have but a faint idea of the sensation 
caused by the appearance of "Uncle Tom's Cabin" and the great part 
this book played in bringing about the abolition of American slavery. 
Mrs. Stowe is referred to here in a spirit of fairness, since the claim 
is not advanced that the old do all the good work, or that all the work 
they do is good. Her history counts on the other side; she outlived 
her usefulness twenty years and gradually lost her memory. The 
charitably inclined will plead her mental failure as an excuse for her 
two books attacking the characters of Lord Byron and his sister, 
charging them with the abominable crime of incest. 



306 ORIGINAL ARTICLES. 

Let US now glance backward at the careers of some of the illus- 
trious dead who have made our country great, and have done g^ood 
work late in their evening of life. 

Benjamin Franklin, philosopher, statesman, and patriot, was 
seventy when he signed the Declaration of Independence; seventy-two 
when he made the treaty with France which sent Lafayette and his 
soldiers to aid Washington in capturing Cornwallis and his army at 
Yorktown, thus securing our independence of Eng^land and giving us 
the opportunity to develop into the great country we now are. When 
he signed the final treaty of peace with England he was seventy-eight. 
He lived six years longer, very much troubled with gout, but with 
clear and unclouded intellect. It is a reasonable conjecture that Frank- 
lin might have lived many years longer except for the onerous duties 
which the ambassadorship imposed on him, depriving him of the fresh 
air and exercise to which he had always been accustomed. The Con- 
tinental Congress was too poor to hire clerks for him. He was obliged 
to do his own drudgery and was greatly overworked. Having been all 
his life very temperate in eating and a consumer of large quantities of 
water, it is very likely that the wines and high living that French polite- 
ness heaped on him helped the gout to break down his natural hardy 
constitution. 

John Adams, second president (1796 to 1800), after retiring from 
the presidency was entrusted by his native state with important matters, 
among them being, when he was eighty-five years old, the drafting of 
a new constitution for Massachusetts. 

Thomas Jefferson, third president (1800 to 1808), effected the 
Louisiana purchase from Napoleon Bonaparte, together with the terri- 
tories from the Mississippi to the Pacific Ocean. This famous achieve- 
ment laid the foundation for the present greatness of our country. 
After retiring he founded the University of Virginia and for several 
years was its presiding officer. He died in 1826, on the fourth of 
July. John Adams died the same date, just fifty years after the signing 
of the Declaration of Independence. 

John Quincy Adams, sixth president (1824 to 1828), retired at 
sixty-two, and after that represented his state in congress nineteen 
years, as long as he lived. His diary, in a number of volumes, is a 
record to the day he fell from his seat in the house. It is valuable as 
historic material. He was eighty-one years old and as bright as at 
any period of his life. 

Albert Gallatin (1760 to i848),statesman, diplomat and scholar, 
of first rank. He was minister to France for seven years. Returning 
from that country when he was seventy-two years of age, he was then 
sent to England on the same mission. On his return from London 
he retired from public affairs and devoted the remainder of his life 
to the study of Indian ethnology. He was a leader in this branch of 
science and consequently an authority. His interest in public as well 



LESSONS IN LONGEVITY. 807 

as his own private affairs was unabated until the last. He died at 
eighty-eight, showing no signs of mental atrophy. 

This list of old working men of our country could be indefinitely 
extended, but to prevent this paper from being too long we will cease 
the enumeration here to make room for reference to some old men in 
other countries. 

William E. Gladstone, the grand old man of Britain, premier for 
the fifth time at eighty-five. It is almost incredible that so old a man 
could have the vigor, mental or physical, to transact so much business 
as the care of the whole British Empire involves. 

Isaac Newton (1642- 1727), physicist and mathematician, is 
another illustrious example of mentality retained in extreme old age. 
He was seventy-four when he solved a problem, proposed by Leibnitz, 
his celebrated German rival, which was puzzling the mathematicians of 
Europe. When he died, at the age of eighty-five years, he was presi- 
dent of the Royal Society. 

The three Herschels, astronomers, all lived to be old and retained 
unclouded minds. That sublime genius, the elder Herschel, the dis- 
coverer of the eighth planet of the solar system, reached eighty-five, 
and the youngest attained nearly the same age. 

Caroline Herschel, the sister and aunt, lived to be much older — 
ninety-eight. She was given a medal by the Ro)ral Society for astro- 
nomical work pursued when she was seventy-eight, and was made an 
honorary member of the society, as was also another woman who lived 
a long life devoted to science. 

Mary Somerville was the author of many books of permanent 
value. Her great work on "Physical Geography," an exhaustive book 
in two volumes, from which all later writers draw their materials, was 
not finished until late in life. Her health remained good and she 
retained an unimpaired mind until the last. . She died at the age of 
ninety-two, in her sleep. 

Before canvassing the rest of Europe for instances of prolonged 
activity let us revert again to the American continent and see what 
our sister republics of Mexico and Canada can add to our list. Here 
is a brief sketch of three Canadians and one Mexican. 

Sir J. W. Dawson, the Canadian geologist, if still alive is eighty- 
six. All geologists recognize the value of his numerous books and 
fossil discoveries, among the most important of which is that of the 
eozoon canadense, so far as yet known, the oldest form of animal life 
that appeared on our planet. He was born in 1820, and began to write 
and publish books in 1847. The first venture was "The Old Red Sand- 
stones of Nova Scotia," and the practice of bookmaking has been per- 
severed in until recently, a book appearing every year or two. In 1893 
he published two— "Salient Points in the Science of the Earth," and 
the "Canadian Ice Age." It was a favorite theme with Dawson to try 
to read geological truth into the first chapter of Genesis. His latest 
books are as good as his first. 



308 ORIGINAL ARTICLES. 

Daniel Wilson was not, like Dawson, a native of Canada. He 
was Scotch by birth and already eminent as an archaeologist before 
leaving Scotland. At about twenty-seven he came to Toronto and 
accepted a professorship in the University, where he remained until his 
demise. He was a prolific writer of books, some of which, like the 
"Missing Link," were on the wrong side of the question, but his educa- 
tional work has seldom been excelled in value and was not impaired 
by age, which did not quite reach the four-score mark. 

Goldwin Smith, perhaps the most illustrious of the trio, is still 
alive at eighty-three. He is English-born and had achieved prom- 
inence before coming to America, having been Regius Professor of 
History for ten years at Oxford, and author of many books of English 
history and biography. After reaching our shore he was for three 
years Professor of History at Cornell, then, in 1871, he accepted 
the editorship of a paper at Toronto, where he has since lived. He was 
fifty-one years old at the time of his elevation to the editorial tripod. 
Since then he has written many valuable books, his forte being history. 
His last work of that kind dates back only nine years. During our 
civil war Goldwin Smith was the solid friend of the Union, and his 
writings had an immense influence in holding England steadily neutral 
and preventing her from giving active aid to the Confederacy. Smith 
is an original thinker and a brilliant writer. His luminous and 
expressive style makes it a pleasure to read anything he writes. Besides 
being a historian he is a scholar, linguist, and translator of the old 
poets — Greek and Latin, and a critic of the first rank. His last volume 
of translations of the Greek tragedies appeared .twelve years ago. How 
long his activity will hold out no one can divine, but there is no sign of 
senility present as yet. 

PoRFiRio Diaz, the president of Mexico, is now seventy-six years 
old. All that the country now is it owes to this able and enlightened 
man who, from the scene of chronic and chaotic revolution has 
changed it to a prosperous and progressive republic, respected by the 
rest of the world. Every well-wisher of the human race must hope 
to see his term of activity last many years more. 

Turning to France, we find many examples of long, active life, of 
which we will quote a few. 

BuFFON, zoologist, lived to eighty-one. 

Voltaire, lived to eighty-four. 

FoNTENELLE (1657-17S7) Hved to OTit hundred. He wrote many 
books in both prose and poetry on music, drama and romance, most of 
which are now forgotten, although famous in their day. He is the 
greatest French humorist and much of his wit is yet extant. His dis- 
position to joke persisted to the very last. As he lay on his death bed 
just before he drew his last breath, his friends standing around to see 
him die, another friend whom he had not seen for a long time came in 
to pay his last respects. Fontenelle faintly recognized his friend and 
this little dialogue followed : 



LESSONS IN LONGEVITY. 309 

Friend: Est que vous souffrez? 

Fontenelle: Non j'n souffre pas, de tout. 

Friend: Ne souffrez pas! Pourquoi etes vous au lit? 

Fontenelle: C'est une certaine, petite difficulte. 

Friend: Une difficulte! Quelle difficulte? 

Fontenelle: C'est une difficulte d'etre. 

With a faint smile on his lips Fontenelle shut his eyes and the next 
moment was gone. 

Coming to Germany, we find so many names of scholars who have 
left us work of permanent value done after reaching the four-score 
mark that it seems invidious to select among them. We will mention 
a few. 

ScHLOSSER ( 1 775-1861), historian, finished his "Weltgeschichte" 
(History of the World) five years before he died. After that he wrote 
his last book, "The Critic of Dante." His industry as a writer was 
remarkable and liis last books were not inferior to the rest. 

Alexander Von Humboldt (1769-1859), scientist, naturalist, 
explorer, lecturer and author, finished the last volume of his greatest 
work, "The Cosmos," during the last year of his life. 

Wolfgang Von Goethe (1749-1832), the immortal, called by his 
contemporaries the all-sided. Goethe is the greatest of German poets 
and the greatest German student of nature. Saying nothing of his 
poetry, his botanical researches, some of which were made after he was 
past eighty, will assure him a place among the revelators of the secrets 
of nature and a fame that will endure as long as civilization itself. 

Italy, the land of song and of great deeds since the first dawn of 
history, has her full share of famous old men, of whom a few will be 
named. 

Louis Cornaro (1467- 1 566), a Venetian nobleman, was rather 
wild in his youth, and at forty had so impaired his health by his riotous 
living and self-indulgence that a fit of sickness overtook him which 
threatened to be fatal. However, he recovered by the narrowest margin 
and lived the rest of his ninety-nine years in a sober, temperate, and 
cheerful manner. At the age of eighty-three he wrote his first book, 
"A Sure and Certain Method of Attaining a Long and Healthful Life." 
At eighty-eight, ninety-one, and ninety-five he wrote books on the 
same subject. The main point in his "Sure and Certain Method" was 
temperance in eating. He subsisted during the latter part of his life 
on one tgg 3. day. 

Michaelangelo (1475-1564), architect, painter, sculptor, and 
poet, and master in all four professions. Among his greatest works 
at Rome are the Sixtine Chapel and Saint Peter's Cathedral. He died 
before he had finished the latter, on which, at eighty-nine, he was still 
at work. He was never married, but after he was past sixty he fell 
violently in love with Vittoria CoUonna. As she was young and beau- 
tiful and he old and very homely he said nothing about it to her, but 
took it all out in writing sonnets to her that are aflame with sentiments 



810 ORIGINAL ARTICLES. 

of love and friendship. He called it Platonic love, but it was probably 
the genuine article. In the fighting line Italy has produced the oldest 
successful general and the oldest successful admiral that history records. 

Enrico Dandolo (1110-1205) was eighty-three when he was 
elected doge of Venice. He had been doge ten years when he laid siege 
to Constantinople and took it, to seat a claimant, Alexius, on the impe- 
rial throne. The next year he started on a crusade with a French army 
to capture the Holy Sepulchre from the infidels, but getting as far as 
Constantinople and learning that the city was in possession of the 
opposite party, who had murdered Alexius, he abandoned his crusade, 
laid siege to the city and took it a second time, by storm, pillaged it, 
and made Count Baldwin, of Flanders, emperor. What adds to our 
wonder is that Dandolo was blind. 

Andrea Doria (1468-1560) was doge of Genoa and one of the 
greatest sea fighters that history mentions. His main business was 
fighting the Turks, who at that time were threatening to overrun 
Europe. He restored the independence of his own country by driving 
out the army of the French king, Francis I, and was oflfered its sover- 
eignty but refused, preferring to be a citizen. Like Washington, he 
was called the Father of his Country. 

Examination of the remaining countries of Europe might aflFord 
equally as good material as that already cited, but this paper is long 
enough now, although one name in Spain ought to be mentioned. 

Cervantes, the author of a book — "Don Quixote" — ^which has 
probably caused more mirth than any other book ever written. He 
did not reach so great an age as some, but he was a man who had 
endured all kinds of hardships, having been a common soldier and a 
slave among the Algerines. It is sufficient to say that he wrote the 
last half of that book after he had past the three-score years and ten. 

Two famous Russians will be noticed in concluding. 

Count Lyof Tolstoi (bom 1828), reformer, author and advocate 
of human rights. Suspected by the Russian government and excom- 
municated by the Russian Church, he is yet as busy as ever with his 
pen in the good cause. 

Metschnikoff (1845), the other famous Russian, has just reached 
Osier's deadline. He is still at the Pasteur Institute in Paris coralling 
the phagocytes, and endeavoring to subject them to order for the pur- 
pose of studying their habits and thereby discovering how to prevent the 
dry rot of old age. He has already made some wonderful discoveries, 
rendering certain things plain that have long been a puzzle. He lives 
strictly in accordance with his own discoveries and theories, and eats 
his curdled milk every day for his regular diet to colonize his intes- 
tinal canal with its bacteria, one of his most practical discoveries 
being that the microbes of sour milk are the most deadly enemies of 
the bacteria of putrefaction, which are always swarming in the intestinal 
canal ready to riot whenever opportunity presents. What MetschnikoflF 
does in this line henceforth will be watched by the world with great 



NECROSIS OF THE MASTOID PROCESS. 311 

interest. He has said lately that the problem of producing something 
practical for the prolongation of life does not seem to present insuper- 
able difficulty. 

The above notices of the work of some old folks could be increased 
indefinitely by including the yet active workers in their eighth decade, 
but enough has been said to show the nullity of Osier's disparaging 
estimate of the value to the world of the old, and we may express the 
hope that he will live to prove it by his own example in his new sphere 
of activity. 

This subject will be resumed in a paper giving the ideas, observa- 
tions, and theories of the writer on the second proposed question — How 
to be alive and stirring when eighty-four years have passed over one's 
head. 



NECROSIS OF THE MASTOID PROCESS. 

WALTER J. BENN, M. D. 

A LABORER, aged forty-two, was brought to me, December i, by his 
brother and sister, who complained that their brother had "something 
the matter with his head." When asked to describe his symptoms, they 
said that he had "acted queer" for about two weeks ; did not seem to 
be interested in his surroundings; was listless and spent his time in 
sitting in absolute idleness; constantly complained of pain and a 
"funny feeling" in his head, and was "getting worse." 

History. — In early childhood, patient was troubled with frequent 
attacks of earache, and occasional discharge from right ear. At the 
age of six, an attack of acute mastoiditis — at which time he "nearly 
died" — resulted in the breaking down of the bony structure sufficient 
to allow pus to escape at a point about three-quarters of an inch pos- 
terior to the attachment of the concha and about the middle of the 
mastoid, this being followed by a speedy apparent recovery. Since 
this first attack, patient has had five similar, though less severe, attacks 
at varied intervals, the last having occurred about "two years ago." 
Patient's general health has been comparatively good. I was unable 
to obtain family history except that two sisters and two brothers are 
healthy. 

Examination. — Pulse, 83 ; temperature, 99^ ; face vacant and 
expressionless; pupils, dilated; watch-tick, at orifice of right external 
auditory meatus, nil ; on right mastoid, nil ; at left orifice, faint ; on left 
mastoid, distinct; on frontal, faint. It was necessary to speak very 
loudly to make patient hear, and he watched my lips to aid him in 
understanding what I said. Right meatal walls swollen, orifice one- 
eighth inch in diameter; left meatal walls swollen, orifice about one- 
quarter inch in diameter ; left meatus full of fresh pus which had dried 
around orifice. There is a cicatrix, one inch long, over right mastoid, 
extending obliquely from a point one-half inch posterior to base of 
suprameatal triangle, downward and backward to a point three-quarters 



312 ORIGINAL ARTICLES. 

of an inch posterior to inferior border of concha. This scar is from 
one-eighth to one-quarter inch wide, and skin is adherent Pressure 
on either tragus and on right mastoid caused vertigo, and nausea fol- 
lowed pressure on left tragus. No pain on pressure of either mastoid. 
Right middle and inferior turbinated bodies hypertrophied posteriorly, 
typical chronic condition; left turbinates slightly hypertrophied; septal 
spur five-sixteenths inch wide, one-eighth inch thick, extending the 
whole length of septum horizontally, about one-eighth inch above floor 
of left nasal fossa; slight ozena in anterior area of left nasal fossa; 
slight ozena in anterior area of left nasal fossa. Posterior walls of 
pharynx hyperemic and covered with white catarrhal exudation ; fauces 
congested; tonsils slightly enlarged. After irrigating with hot water, 
swelling subsided sufficiently to admit speculum, and I found right 
tympanum externum and ossicles absent ; inferior posterior two-thirds 
of left tympanum externum absent, the free border of the remaining 
third smooth and crescentic. 

Diagnosis, — Chronic mastoiditis, suspicion of necrosis, right side; 
chronic suppurative otitis media, left side. 

Trcahnent. — I recommended complete mastoid operation as the only 
means of curing the condition on right side, but neither patient nor 
his friends would consent to this. I did not feel that I could obtain 
satisfactory results in any other way, but agreed to attempt a cure by 
medication alone. I instructed patient to irrigate the meati four times, 
at intervals of two hours, with water as warm as could be borne, and 
to return the following day. 

On December 2, 1905, I irrigated meati with warm boracic acid 
solution, and discovered right posterior meatal wall to be soft and of a 
brown color. With a cotton-tipped applicator, I broke through this 
wall, and disclosed a large sequestrum, the odor from which was very 
offensive. After removing about a drachm of necrosed tissue, I found 
that the applicator entered both the antrum and the tip of the mastoid, 
the intercellular structure having necrosed and left a cavity between 
the superior, anterior and inferior meatal walls and the external plate 
of the mastoi(^ This cavity I filled with boracic acid solution, and with 
the cotton-tipped proble I removed what I could of the necrosed tissue. 
I then had the patient turn his head to the left and filled the cavity 
with a one to one thousand solution of alphozone, allowing this to 
remain in the cavity twenty minutes. I then dried the diseased surface 
and packed cavity with moist, five per cent iodosyl gauze. This line 
of treatment was followed, daily, for a month, and at each sitting I 
sprayed the nasal fossae with alkaline solution and nebulized with 
camphomenthol compound in abolene, with very little change in con- 
dition except that there was a brighter appearance of the face and a 
more comfortable feeling on the part of the patient. 

On January 2, 1906, I removed the septal spur. After the first 
month, I added to the treatment a second irrigation consisting of a 
solution — two grains to the ounce — of potassium permanganate, which 



GASTRIC SURGERY. 313 

I forced through the Eustachian tube, with Politzer bag, from without 
inward, and discontinued the alphozone. At the close of the third 
month no more necrosed tissue followed either the irrigation or the 
probing, and I then discontinued the iodosyl gauze packing, the alkaline 
spray and the nebulization. 

Since April i treatment has been as follows: Warm water irriga- 
tion; glycothymoline (full strength) dropped into cavity; alcohol 
dropped into cavity (each application of liquid being forced through the 
Eustachian tube and the cavity thoroughly dried after each application) ; 
insufflation with powder ccwnposed of twenty parts camphor and eighty 
parts boracic acid ; a final Politzerization and a loose packing with cot- 
ton. Treatment every second day from April i to June i. On June 
4, patient went to work in the shipyard, and was instructed to call 
Wednesdays and Saturdays, and, on June ii, I obtained the last sign 
of pus. 

As this article treats of necrosis of the mastoid, I have purposely 
omitted treatment of the left ear, and will only say that I followed a 
similar line of treatment to that indicated for the right ear. 

In conclusion, I, will say that the patient continues his work at the 
shipyard ; is cheerful and comfortable ; hears and understands an ordi- 
nary conversation at a distance of two feet without watching the lips ; 
claims to hear the watch-tick against right meatal orifice and can hear 
it, distinctly, at a distance of fourteen inches from the left ear. The 
left tympanum externum has reformed with the exception of a central 
perforation the size of a small pinhead. I am continuing the treatment 
twice a week, with slight modification, although I consider the patient 
practically discharged. 

Bay City, Michigan, 

ORIGINAL ABSTRACTS. 



SURGERY. 

FRANK BANGHART WALKER, Ph. B., M. D. 
rRonosoK of surgbrt and opbrativs surgbry in tmb obtroit postgraduatb school of mbdicinb; 

ADJUNCT PROPBSSOR OP OPBRATIVB SURGBRY IN THB DBTROIT COLLBGB OP MBDICINB. 

AND 

CYRENUS GARRITT DARLING, M. D. 

CLINICAL PROPBSSOR OP SURGBRY IN THB UNIVKRSITY OP MICHIGAN. 



THE PRESENT STATUS OF GASTRIC SURGERY WITH 

SPECIAL REFERENCE TO THE TREATMENT OF 

CHRONIC ULCER. 

Louis Frank, M. D., of Louisville, Kentucky, in American Journal 
of the Medical Sciences for June, 1906. 

The first portion of the paper deals with the historic part of gastric 
surgery. The oldest operation on the stomach for the extraction of 
foreign bodies was performed by Crolius, in 1602, to remove a knife. 



314 ORIGINAL ABSTRACTS. 

Though this was successful only thirteen cases had been reported to 
1887. The first gastrostpmy, unsuccessful, was done in 1839, by 
Sedillot. Pylorectomy was first performed by Pean, in 1879. The 
first gastroenterostomy was f)erformed by Wolfler, in 1881. This was 
done to procure rest for the stomach. The entire removal of the 
stomach, which was first successfully performed by Schlatter, since 
then by Bernays, Richardson, and a few others, is so rardy done that 
we may dismiss it from our consideration of chrqEic ulcer. 

In the treatment of cancer of the stomach we are concerned with 
the proposition. Is the disease removable, and, if not, can anything be 
done to prolong the patient's life, or relieve the starvation and pain 
caused by obstruction? This condition, if left alone, has but one 
ending and that is fatal. While having profound respect for laboratory 
findings, he does not believe it best always to wait until all clinical 
suspicions have been confirmed by these methods. Many patients 
would submit to an operation if it were not for the fact that the family 
physician often counsels against the advice of the surgeon, thus in 
many instances causing a fatal delay. Cancer, no matter where located, 
should always be removed upon the slightest suspicion, and the mere 
fact that a tumor is present does not prove that it is beyond removal. 

Chronic gastric ulcer, in the opinion of many, should be treated by 
gastroenterostomy. He lays special stress upon the advice of Deaver, 
who recommends gastroenterostomy for complications and sequelae of 
gastric ulcer; in fact, in all diseases of the stomach where gastric 
contents are not evacuated. 

It is understood that the principal dangers of gastric ulcer are 
hemorrhage and perforation. The direct treatment of hemorrhage 
by excision of the ulcer, or direct treatment of the bleeding point when 
it is possible, leads only to good results. Gastroenterostomy has given 
the same results in the author's cases. Others have reported deaths 
from hemorrhage following gastroenterostomy. 

Perforation is liable to occur in the mildest case of gastric ulcer. 
The symptoms of perforation are well known. There is only one 
course to pursue after the perforation has taken place. The operation 
of choice in ulcer is a properly performed gastroenterostomy. The 
mortality of this operation does not exceed fifteen per cent. Symp- 
toms of ulcer are always well defined. Pain indicates a relatively 
advanced progress of the disease. Vomiting and nausea may be con- 
sidered of only corroboratory value. Periodic attacks of headache are 
frequently coincident with gastric trouble. His picture of a victim is 
so vividly drawn that it should be given in full: "There are few 
beings so abjectly miserable as those who are the victims of intractable 
dyspepsia. The meal-time, which should be a delight, is a time of 
despair and foreboding. The keen relish of good food, which the 
man in physical health should appreciate, is a joy unknown or long 
forgotten to the dyspeptic. A patient who has misery written in every 
wrinkle of a thin, haggard face; who by reason of long suflFering and 



MEDIAN LONGITUDINAl, INCISION. 316 

bitter experience has felt compelled to abandon first one dish and then 
another, until only fluids alone can be taken, and these not always with 
impunity; a patient, to say the truth, whose life becomes embittered 
by the pangs of a suffering which he must inflict upon himself, — ^this 
patient will find, if a gastroenterostomy be done for the chronic ulcer, 
which is the source of all his trouble, that his return to health and 
appetite is at first almost beyond belief." 

The paper closes with a respectful consideration of the gastric 
analyst, whose opinions should be tolerated, but accepted only when 
they fit in with clinical facts. When in doubt, use the exploratory 
incision. c. G. d. 



GYNECOLOGY. 

REUBEN PETERSON, A. B..M.D. 

PROPBSOR OF GTKBCOLOGT AND OBSTBTUCS IN THB UNIVBRSITT OF MICHIGAN. 

AND 

CHRISTOPHER GREGG PARNALL, A. B.. M. D. 

PORMBRLT FIRST ASSISTANT IN CTNBCOLOGT AMD OaSTBTRXCS IN THB UNITSRSITr OF MICHIGAN. 



SHORTENING OF THE ROUND LIGAMENTS WITHIN THE 
INGUINAL CANALS, THROUGH A SINGLE SUPRA- 
PUBIC TRANSVERSE OR MEDIAN LONGITU- 
DINAL INCISION. 

Peterson (Surgery, Gynecology, and Obstetrics, Volume III, Num- 
ber I) describes an operation used in the gynecologic clinic of the Uni- 
versity of Michigan Hospital during the last year. For the correction 
of retyodisplacements of the uterus the author had found Alexander's 
method the most satisfactory, when conditions permitted its utilization. 
However, the Alexander operation is limited in application to cases of 
nonadherent uteri, two incisions are necessary, and additional intrapel- 
vic work is not usually feasable on account of technical difficulties 
arising from the location of the incisions. 

In order to retain the principle of the Alexander operation, and at 
the same time to overcome its disadvantages, the writer has introduced 
a new method of shortening the round ligaments. A transverse incision 
is made down to the fascia just above a line joining the two pubic 
spines. The upper edge of the incision is retraced upward and the fascia 
exposed for two inches or more. The fascia is incised longitudi- 
nally in the median line, the rectus fibres separated, and the trans- 
versalis fascia and peritoneum opened high up to avoid the bladder. 
Adhesions of the uterus and adnexa may now be broken up and any 
other intrapelvic procedure can be carried out with ease. One angle of 
the incision is then retraced downwards and outwards, and the fascia 
cleared by blunt dissection over the external ring which is always 
located at the base of the pubic spine. The canal is opened on a 
grooved director, nerve filaments isolated and drawn aside, and the 



316 ORIGINAL ABSTRACTS. 

round ligament sought for just inside and below the edge of the inter- 
nal oblique muscle. The peritoneum is now stripped back for several 
inches. The opposite side is treated in the same manner. Both liga- 
ments are drawn up while a finger inserted through the peritoneal 
incision holds the uterus well up and forward so that the cervix points 
downwards and backwards in its normal direction. The ligaments are 
now seized by hemostats at the level of the internal rings to indicate 
the amount of shortening necessary. The nerve is released and 
the ligament secured to the under surface of the fascia by a modified 
mattress suture of catgut. The edges of the fascia are united by a 
continuous suture. After closing the inguinal canals the median 
incision is closed by tier sutures of catgut. Care should be taken in 
approximating the superficial fat that all dead space is obliterated by 
appropriate sutures. The skin incision is closed as the operator desires. 
No drainage is necessary. 

The above principle of shortening the ligaments through a single 
incision can be applied with the usual median longitudinal incision, 
which is preferred when extensive abdominal work is necessary. 

JackioHt Michigun. C. G. P. 



OBSTETRICS. 

WILLIAM HORACE MORLEV, Ph.B., M.D. 

DBMONSTRATOR OF OBSTSTItlCS AMD CYNBCOLOGY IM THE UmVBRSITY OP MICHIGAN. 

AND 

WALES MELVIN SIGNOR, M.D. 

FIRST ASSISTAKT IN OBSTBTRICS AND GYNBCOU>GY IN THB UNIVBRSITY OF MICHIGAN. 

"ANESTHESIA IN THE FIRST STAGE OF LABOR." 

Newell {Surgery, Gynecology, and Obstetrics, July, 1906), under 
this title, advances the idea that the older beliefs with regard to the 
time at which the anesthetic should be given in conducting a labor are 
not applicable to the present status of civilization. As an excuse for 
the use of ether or other anesthetic in the first stage, he maintains that 
the modern method of life has removed women irom the normal stand- 
ard, and hence makes of every case of confinement one requiring the 
special attention advised for all abnormal labors. 

As a result of racial progress womankind is less able to stand the 
pain incident to the labor, and is entitled to relief as soon in the labor 
as the pain becomes severe. This prevents a shattering of the nervous 
system by the strain and makes the woman more willing to undergo 
a second conception. He states that a majority of his series of cases 
have been terminated by the application of low forceps. "This has 
not been due to the effect of the ether on labor pains, but to my own 
personal belief that the nervous and physical exhaustion entailed by 
a more or less severe second stage will do more permanent harm than 
a carefully performed operative delivery." 

In support of his views he holds that the labor is not prolonged ; 



RADIANT ENERGY. 317 

that there is no apparent increase in the tendency to postpartum hemor- 
rhage; and that the infant mortality is not necessarily increased. In 
regard to the last point, he says that a deep etherization is often present 
in the child requiring careful resuscitation. He believes that the spasm 
of the cervical muscle is lessened and the dilatation of the cervix 
hastened by the use of anesthetic. 

A further portion of his article deals with the use of scopolamin 
and morphin for similar anesthetic purpose in obstetric work. In this 
he points out the dangers of the drugs and that further experience may 
be advisable before they be taken into general use. In conclusion he 
gives comparisons between the different forms of anesthetization as he 
has met them in his work. w. M. s. 



PEDIATRICS. 

ARTHUR DAVID HOLMES, C. M., M. D. 



HYDROCEPHALUS AND RACHITIS TREATED BY 
RADIANT ENERGY. 

Doctor Margaret Cleaves (Archives of Pediatrics, February, 
1906) says: "Judging from the patholggy of hydrocephalus that the 
X'TSlj which is able to penetrate so deeply as to outline not only the 
bony structures, but internal organs, tuberculous lesions, thstt produces 
disturbances of the cellular equilibrium of the blood, that is destructive 
of germ life, and that can atrophy the Graffian follicles, can with per- 
fect reason be expected to penetrate the cranial bones and act upon 
the thickened granular ^endothelium and to promote and stimulate 
nutritive changes." 

The author reports two cases, one of congenital internal hydro- 
cephalus, and one which had been four times diagnosed as primary 
hydrocephalus and in which a rachitic element was recognized. In 
both cases good results were secured. Doctor Cleaves said that her 
paper was not presented with the thought that in radiant energy is to 
be found a panacea for hydrocephalus and rachitis, but to call the 
attention of the profession to the results obtained in the cases reported 
that the way may open for further investigation of the subject. 

Treatment should be instituted upon the first manifestation of 
disease, even immediately after birth in congenital hydrocephalus, but 
it should be administered with a full knowledge of the physics, physio- 
logic action and therapeutic technique of radiant energy, superimposed 
upon a knowledge of the pathology underlying the condition. 



COMPLICATIONS OF SCARLET FEVER. 

Hunter writes (British Medical Journal, February 24, 1906) that 

in addition to the specific symptoms of this disease some cases present 

rigors and diarrhea, while a few have pains in the limbs and others 

epistaxis. The rash appears (in his series of one hundred fifty cases) 



318 ORIGINAL ABSTRACTS. 

in half the cases on the seccmd day, and in eighty per cent on the 
first three days of the illness. The rash lasted five days in more than 
half the cases. Desquamation began usually at the root of the neck 
and in most cases within the first week. The complications are set 
down as follows: Adenitis, nineteen per cent; albuminuria, of two 
or more days' standing, twenty-one per cent; actual nephritis, 2.8 per 
cent ; otorrhea and otitis, 6.4 per cent ; rhinitis and rhinorrhea, 64 per 
cent ; rheumatism, 4.3 per cent ; secondary tonsillitis, 3.5 per cent We 
also find mastoiditis, meningitis, optic neuritis and ocular paralyses 
coming on after some cases of this disease. On the whole, a severe 
rash is more likely to be followed by complications than is a mild one. 
There seems to be no definite relation between the height of the 
temperature and the occurrence of complications. The severity of 
the disease and the septic complications of it are largely influenced 
by the degree of oral sepsis in the patient when the disease commences. 
Of cases without oral sepsis only thirty-five per cent had complications 
of moderate or severe degree, whereas of cases with oral sepsis sixty- 
five per cent developed such complications. Our first duty is, there- 
fore, in every case to get rid of this great danger, oral sepsis, as far 
as possible. 



PREVENTION OF TUBERCULOSIS AMONG SCHOOL 

CHILDREN. 

Doctor Vautier, of Paris, in a paper in the Revue d' Hygiene et de 
Medicine Infantiles, Paris, 1905, Volume IV, pages 691 and 723, has 
reached the following conclusions: In the common schools of Paris 
tubercular contagion appears to us to be very rare. This contagion may 
be produced in a family during the school age, but even that is not 
frequent. The number of children of school age, who have clearly 
pulmonary tuberculosis is very small. Children, in a great majority of 
cases, at least among the poor, are infected by latent tuberculosis at 
the time of their entrance into school. He therefore proposes the fol- 
lowing rules and regulations : 

(i) Add to the instructions given relative to the construction of 
school buildings, a rule favoring facing the building so that the sun's 
rays may penetrate the class rooms and court. 

(2) Replace wooden floors by those without joints in schools to 
be built, and, if possible, in those already built. 

(3) Exclude children who have evident tuberculosis, except that 
surgical tuberculosis may be so protected by air-tight dressing as to 
be safe. 

(4) Send away members of the teaching force who have evidences 
of tuberculosis, or put them in places where they will not come in con- 
tact with children. 

(5) Have schoolrooms thoroughly cleaned. 



OBSERVATIONS* ON BROKEN NECKS. 319 

(6) Seek to increase the strength of children by walks and games 
for which open lawns are necessary. Fortifications or the space about 
them are all that is necessary. 

(7) Insist that the schoolmasters advise cleanliness and if need be, 
require it, and that they make it possible for children to know the 
meaning of a bath. 

(8) Insist on obtaining from the boards of health, proper aeration 
and size for homes and disinfection of places occupied by bacillus- 
bearing tuberculous patients, especially at the time between the depar- 
ture of the infected family and the entrance of another family. 

(9) Invite the school boards to consider the matters of better food 
for the children, furnishing a meal to many of them and making 
arrangements for free medicines, especially those prescribed by the 
attending physician. 

(10) Send children convalescent from acute sicknesses, especially 
those likely to become tuberculous: measles, pertussis, et cetera, to 
special institutions in the country. 

(11) Establish seashore hospitals at convenient places, where tuber- 
culous children may stay six months or a year, and receive suitable 
treatment. 

ORTHOPEDICS. 

IRA DEAN LOREE, M.D. 

PIKST ASSISTAKT IN SUKGBRT IN THB UNIVBKSITY OP MICHIGAN. 



OBSERVATIONS ON BROKEN NECKS. 

Reginald H. Sayre, M. D., of New York {American Journal of 
Orthopedic Surgery for April, 1906), first corrects the deformity and 
after placing his patient in the Sayre position retains it by means of a 
plaster-of -Paris jacket and helmet. Immobilization may be obtained 
by extension to the head while liquid plaster-of-Paris is poured about 
the head and neck or supported by sandbags. 

Paralysis often recurs, hence it is necessary to keep the parts at 
rest for a longer period than in an ordinary fracture. He does not 
state any required length of time (no doubt it differs in individual cases), 
but it is generally necessary to support the parts by means of a jury- 
mast or other like apparatus after the patient is allowed to be up. 

He has had in his practice eleven cases with results as follows : In 
four there was a complete cure. Two had muscular control but there 
remained some stiffness. One patient required support to the head; 
however, he had good control of all muscles. Two remained para- 
lyzed in the lower extremities. One died soon after injury and one 
was under treatment at time of his report. In those cases where 
complete readjustment is secured he expects a perfect cure. If paraly- 
sis persists after manipulation he advises laminectomy. 



320 ORIGINAL ABSTRACTS. 



LARYNGOLOGY. 



WILLIS SIDNEY ANDERSON, M. D. 

ASSISTANT TO THE CHAIR OF LARYNGOLOGY IN THE DETROIT COLLEGE OF MEDICINE. 



THREE CASES OF ETHMOFRONTAL SINUSITIS WITH 

SPONTANEOUS EVACUATION THROUGH THE 

ORBITAL REGION. 

Saint-Clair Thompson (Revue Hebdomadaire de Laryngologie, 
d'Otologie et de Rhinologie, June 30, 1906) calls attention to the com- 
parative rarity of sinusitis opening into the orbit. 

The first case reported was that of a woman aged eighteen, who 
had an abscess at the level of the left eye following influenza. The 
symptoms were those of ethmoid, frontal and maxillary sinus suppura- 
tion. Incision and evacuation of the pus cured the patient without 
further operation. 

The second case was that of a boy, aged eleven, who had an abscess 
of the frontal sinus following a cold. An incision was made, and pus 
evacuated containing the micrococcus catarrhalis in pure culture. The 
sinus was drained through the anterior wall and cure resulted. There 
was no pus found in the nose. 

The third case was that of a woman, aged twenty-five, who had 
chronic sinusitis with acute frontoethmoidal exacerbations. The exter- 
nal abscess was incised, a fistula remaining. Two months later an 
operation demonstrated that the fistula led to an anterior ethmofrontal 
cell. Several operations were necessary befqre a complete cure resulted. 

The author compares these cases with abscess in the mastoid region. 
If the infection is recent, then incision is sufficient as in the first case. 
More severe cases require incision and drainage as in the second, while 
severe cases require radical operative treatment, as in the third. Trans- 
illumination was of value in the first case, where only one side was 
involved. The absence of fever and general symptoms were charac- 
teristic of these cases. 



PROCTOLOGY. 

LOUIS JACOB HIRSCHMAN. M. D. 

CLINICAL PROVBSSOR OF PROCTOLOGY IN THB DBTROXT COLLBGR OF MBOICINR. 



THE OFFICE TREATMENT OF INTERNAL HEMORRHOIDS 

BY OPERATION. 

• 

In the March, 1906, number of The Therapeutic Gazette, Tuttle 
states that the operative treatment of hemorrhoids in office practice 
resolves itself into excision with suturing of the edges, or ligature with 
or without transfixion. He discards the cautery on account of the 
radiation of heat beyond the anesthetized area. The ligature is the 
easiest, quickest and most satisfactory in the majority of cases. He 



MULTIPLE SCLEROSIS. 321 

describes his technique thusly: After the parts are thoroughly steril- 
ized, he injects twenty or thirty minims of a half per cent solution of 
cocain into the region of the lesser sphincterian nerve on either side 
of the posterior commissure. After waiting three minutes a duckbill 
speculum is introduced into the anus, and with this held firmly at the 
anterior commissure, the sphincter is massaged with the finger for five 
minutes, until it becomes loose and placid. Care should be taken to 
avoid traumatism to the mucous membrane. After dilatation is accom- 
plished, the hemorrhoids are caught one by one and injected with a 
one-tenth per cent solution of cocain, and dissected up until a narrow 
pedicle is formed well within the rectum. If the blood-vessels are 
large, he transfixes with a double-threaded needle and ties on either 
side, otherwise a single ligature around the mass suffices. The tumor 
is then cut off below the ligature. After all the hemorrhoids have 
been removed, he applies adrenalin solution to prevent subsequent 
oozing, and the patient is allowed to go after a few minutes rest. The 
operation may be modified by suturing the edges of the mucous mem- 
brane, but Tuttle sees no advantage over the ligature, and he rarely 
employs it. 

NEUROLOGY. 

DAVID INGLIS, M. D. 

PROFBSSOR OP NBRVOUS AND MENTAL DISXASBS IN THB DBTROIT COLLBGB OF MROICINB. 

AND 

IRWIN HOFFMAN NEFF, M. D. 

ASSISTANT PHYSICIAN AT THB BASTBRN MICHIGAN ASYLUM. 



MULTIPLE SCLEROSIS: A CONTRIBUTION TO ITS CLIN-* 
ICAL COURSE AND PATHOLOGICAL ANATOMY. 

Taylor again states (Journal of Nervous and Mental Diseases, 
June, 1906) the now well-recognized fact that multiple sclerosis is 
more common, especially in this country, than we have formerly sup- 
posed. He gives a resume of the reports on this disease, and also 
reports twelve cases illustrating some of the difficulties of diagnosis 
and exemplifying the necessity of a thorough consideration of every 
case before the diagnosis of multiple sclerosis is excluded. Separate 
paragraphs are devoted to the frequency, diagnosis, prognosis, and 
pathological anatomy of the disease. Taylor believes that the diag- 
nosis of multiple sclerosis is often absolutely impossible to make with 
assurance during life, even in advanced stages of the disease. He 
furthermore says that it is likewise possible that the diagnosis made 
relatively early in the disease may give place to another as the process 
extends. The writer also inclines to the view that the etiol(^;y of the 
disease is still obscure and ventures the supposition of a selective poison 
acting through the blood-vessels. Our chief interest, he says, still 
centers, as it has in many years past, in the pathologic anatomy of the 
condition, and in this field much interesting and important work has 



322 ORIGINAL ABSTRACTS. 

been done, with an alteration of opinion regarding the character of 
pathologic process. The article is a valuable edition to this supposedly 
rare disease and an extensive bibliography appended enhance the value 
of the paper. 

The general conclusions given by Taylor are as follows: 
(i) The rarity of the disease in this country has been overesti- 
mated. A more careful examination of atypical cases and a more open 
mind in diagnosis is desirable. 

(2) The importance of observing and properly estimating minor 
symptoms of the disease, particularly unexplained spasticity and ocular 
disorders, must be emphasized. 

(3) The etiology remains obscure. The pathological anatomy is 
still a hopeful field for study. Present evidence points towards a pri- 
mary destruction of the myeline with either a secondary or coincident 
proliferation of the neuroglia. i. h. n. 



ITHE ADVISABILITY OF ELIMINATING THE TERMS 
MENIERE'S DISEASE AND MENIERE'S SYMP- 
TOMS FROM OTOLOGIC NOMENCLATURE." 

Emil Amberg (American Journal of the Medical Sciences, July, 
1906). Amberg's article is made up largely of excerpts from contrib- 
utors to this disease. The concluding paragraph quite well expresses 
the author's opinion of the symptom complex, and is as follows : 

"We do not speak nowadays of heart disease or of heart symptoms, 
of lung disease or of lung symptoms, nor of kidney disease or of kid- 
ney symptoms. We are expected to diagnose and name a recognizable 
affection of these organs more definitely, and if this is impossible, in 
some instances, we leave the question open with the understanding that 
further investigation is required to clear up some dark points. The 
same rule, I think, should be followed in otitis interna." 

The author furthermore believes that the "Meniere's symptom" can 
be produced: (i) Through influences from the external and middle 
ear; (2) through diseases of the labyrinth; (3) through diseases of 
the brain and of the acoustic nerve; and (4) through neurosis, for 
example, of the sympathicus (angioneurosis). 

The author's conclusions are as follows: 

( 1 ) The triad — hardness of hearing, vertigo, and tinnitus — is given 
as constituting the functional disturbance observed in the so-called 
Meniere's disease. 

(2) These symptoms occur also in numerous affections which are 
not based on the pathologic finding as described by Meniere in his 
historic case. 

(3) The observation that not always a typical picture is present has 
led to the introduction of other terms, such as "Meniere's symptoms," 
et cetera, which has proved to be confusing. 

(4) Even affections of the middle ear, of the outer ear, or of other 



SPECIFIC FOR SEASICKNESS. 323 

parts of the body can cause the symptoms described by Meniere. 

(5) These latter causes can be diagnosed in many instances and 
prove the existence of a great group of affections characterized by 
functional disturbances of the inner ear. 

(6) By abandoning the terms "Meniere's disease" and "Meniere's 
symptoms" a more definite nomenclature can be introduced. This is 
important not only from a physiologic and patholc^ic, but also from 
a clinical standpoint. By using, for instance, the terms "otitis interna 
syphilitica," or "leukemica," or "angioneurotica," or "gastrica" a clear 
conception of some affections would ensue. 

(7) The various terms should be agreed upon. The many inter- 
national medical meetings give ample opportunity for such a procedure. 

I. H. N. 



THERAPEUTICS. 

DELOS LEONARD PARKER, Ph. B., Hi. D. 

LBCTURSR ON MATBRIA MBDICA IN THB DETROIT COLLBGB OP MBDICINB. 



ATROPIN AND STRYCHNIN COMBINED, A SPECIFIC FOR 

SEASICKNESS. 

Brigadier-General Alfred C. Girard, United States Army, 
retired (Jama, June 23, 1906), in a paper presented to the Inter- 
national Medical Congress held at Lisbon in April of this year, sets 
forth his ideas, which he has held since 1888, concerning the value of 
atropin and strychnin in seasickness. At the outset, Doctor Girard 
says: 

"For many years I had believed that I was the original discoverer 
of this treatment, but it seems that other physicians have used it at 
times independent of my investigations, and I, therefore, do not pretend 
to absolute originality, but I believe this report represents the views 
of many observers working subject to my instructions under various 
circumstances, and more than any individual views will establish the 
value of the treatment." 

The treatment consists of hypodermic injection of atropin sulphate 
grains 1/120 (0.0005 milligrams) with strychnin sulphate grains 1/60 
(o.ooi milligrams). This should be administered at the beginning of 
a voyage, or when the sea begins to be rough, or at the advent of a 
storm when the motion of the water causes nausea. In persons not 
readily affected by belladonna the dose may have to be repeated once 
or twice at hourly intervals. The signs for stopping further use of 
the drugs are dryness of the throat and disturbances of vision. Prac- 
tically always, however, the seasickness is corrected, if not before, at 
least by the time incipient S3miptoms of the effects of the belladonna 
are made to appear. 

The advantages claimed for hypodermic medication in this disease 
are the rapidity and certainty with which effects are produced, and 



324 EDITORIAL COMMENT. 

the control it gives over the amount of drugs actually taken up by the 
circulation. Medication by mouth is uncertain, not only as to retention 
by the stomach, but also as to absorption by the blood even when 
retained. 

As a rule a single dose is sufficient for a voyage, but on long trips 
or trips beset with severe weather the medication may have to be 
repeated. 

'The rationale of the treatment may be found in the stimulating 
effect of the atropin on the circulation in the brain, while the strychnin 
causes a similar action through the spinal cord in the respiration." 

Doctor Girard says that from his own experience and observation, 
and from the reports of medical officers that have made use of the 
treatment, he is satisfied the remedy is a specific. He concludes his 
paper with a long list of letters and reports from medical officers 
serving on army transports and on other ships, and the tone of these 
reports shows that actual experience with the remedy has converted 
them all into believers in its efficacy. 



EDITORIAL COMMENT. 



DISCORD AMONG DOCTORS. 

Indications of dissatisfaction are quite apparent in various sections 
of the country regarding the management of the American Medical 
Association, and in certain sections the reaction has been so intense 
as to force expression in effort to establish independent organizations. 
It would be absurd to deny that some cause for provocation exists. It 
would likewise be absurd to decry a laudable movement because affairs 
are not managed in accordance with individual idea. Organizations 
are generally conducted for the benefit of the majority, and no very 
substantial reason obtains to prove the American Medical Association an 
exception to the rule, notwithstanding a feeling prevails that the 
national guild is being manipulated by a selfish minority. However 
this may be, grievance has certainly been incited, as is evidenced by 
complaint from every point of the compass, as well as by contention in 
several quarters for secession from the parent body and inauguration 
of an entirely new regime. 

* 4e * 

Michigan has recently declared for "quality" in contradistinction to 
"quantity." The pronouncement emanates from Grand Rapids doctors, 
and proposes a State Society wherein "the advancement of the science 
of medicine and surgery will be the paramount purpose." The insti- 
gators of the scheme advocate allegiance to the Code of Ethics adopted 
by the American Medical Association in 1847, and disclaim, in the 
following terms, intention to antagonize existing organization : ^ "We 



DISCORD AMONG DOCTORS. 325 

do not advocate the refounding of^a body whose function it shall be to 
antagonize the present societies, except, of course, insofar as member- 
ship in it would require nonaffiliation with any and all of them. If We 
advocate an ethical society in the interest of scientific medicine and 
surgery, not of politics and commercialism, and one, moreover, to which 
we may belong with credit to ourselves, and to which we may point 
with pride and affection, f What we propose, therefore, is not of the 
nature of a secession from the present state body, but a reentering 
upon the historical path from which it so radically diverged in 1902." 

* 3k 4e 

The restriction of membership to quality naturally raises the ques- 
tion of standard for this prerequisite. A limitation of similar import 
has been declared through the Southern medical press, the only excep- 
tion being that Dixie exclusiveness contemplates cutaneous pigment 
rather than cerebral possibility. The Michigan State Medical Society 
certainly experienced a long siege of numerical limitation, and, as 
regards quality of membership, the moral, medical, and mental stand- 
ard averaged no higher than since reorganization became vogue. A 
great deal of discussion might be advanced along this line, but an 
article in a recent issue of the Lancet-Clinic regarding the exclusive- 
ness of scientific societies in general contains a few sentences which 
seem especially applicable to this particular instance, and hence editorial 
prerogative is relinquished to contemporaneous expression : If "Medical 
societies should he organized solely for the advancement of science and 
the love of truth, and they should stand with outstretched arms to 
welcome all who are willing to receive and ready to impart information 
and knowledge. If Societies which are unnecessarily exclusive are 
necessarily narrow, prejudiced and bigoted, and their work will even- 
tually partake of the same character. If Additions to the societies are 
dominated by the same influences, and new members are qualified by 
personal rather than scientific attainments. ^ These societies, like all 
organizations in general, are made up of the good, bad and indifferent, 
and the close affiliation and exclusion impart to mediocrity a false, 
fictitious value and an intolerable air of self-satisfaction. ^ Their 
weakness is readily apparent, and their undoing is a matter of easy 

accomplishment." 

* * * 

Georgia is reported to be engaged in forming an Independent State 
Medical Society, and a G^nfederacy of Southern Medical Associations is 
suggested by a Southern medical journal. In fact a movement which 
points in that direction has already been inaugurated by the Arkansas 
State Medical Society, which lately appointed a committee to formulate 
plans for the establishment of a guild to be known as the Southwestern 
States Medical Association, and composed of the present State 
Medical Societies of Arkansas, Kansas, Missouri, Oklahoma, and Texas, 
the procedure foreboding eventual secession from the American Medical 
Association. 



326 EDITORIAL COMMENT. 

The foregoing are some straws that indicate which way the wind is 
blowing, and it behooves the trustees and councilors to take cognizance 
of belligerent possibilities before the stage is reached where forbearance 
will cease to be a virtue. On the other hand, physicians should bear 
in mind that Rome was not built in a day. Time is required to perfect 
medical organization, and due allowance should be made for rodks and 
shoals encountered along the coast. The organization movement is 
indeed commendable and deserves hearty support, but the fact that 
four years of arduous work has brought only about four per cent of 
the profession into the fold seems to have created the impression that 
possibly an entire change of policy is the desideratum essential to 
insure wholesome success. 



ANNOTATIONS. 



THE UBIQUITY OF CELL UNDERSTANDING. 

Baugh, of Canada, has offered some unique speculations on the 
origin of the human mind, tracing the development of cell intelligence 
from the ovum and spermatozoon to the fully matured comprehension. 
That these generative units possess cell intelligence is manifested by 
their inevitable union, the struggle for supremacy between the count- 
less spermatozoa, and the final entrance of the victor into the female 
cell. The development of mind is evidenced by the evolution of cell 
understanding into the immature child brain, and eventually into the 
complex adult mentality. The prenatal mind is influenced by trans- 
mitted impressions through the mother, and the organism only bec(»ncs 
conscious. of its being at birth, when, free from maternal influence, it 
delineates its own course. All cells are endowed with the faculty of 
choice, and their motility does not give rise to cell understanding, the 
reverse being true. The most minute particle of animate material pos- 
sesses the power of generation, and also the faculty of producing a 
complex organism. The same intelligence which is apparent in animal 
cells is likewise manifest in plants, flowers and fruit, the phenomenon 
of cell intelligence therefore being ubiquitous. 



MALARIA ASCRIBED TO ANKYLOSTOMA DUODENALE. 

While the dissemination of malaria has almost universally been 
ascribed to the pestiferous mosquito, the recent labors of Doctor Sehr- 
wald, a Brazilian physician, with the Ankylostoma Duodenale, or hook- 
worm, seems to emphasize the contention of certain authorities as to 
the prevalence of other methods of conveyance. In a number of cases 
of malaria under his observation, the investigator found the hookworm 
lodged in the intestinal tract of the victim. Serial sections of the para- 
site indicated that the malarial organisms wander from the intestine of 



PHYSICIANS AND PHILOSOPHERS. 327 

the worm into the mouth. The secretion of a peculiar fluid by the 
hookworm prevents the coagulation of its host's blood at the point to 
which it is attached, and that the transmission of the malaria parasite 
from the mouth of the worm directly into the blood of the person can 
readily be accomplished, is easy of conception. While no observations 
have been made with regard to transmission of the disease from person 
to person, by means of the eggs or larvae of the hookworm, the inves- 
tigator ventures the assumption that infection may occur in this way. 
Submitting that the theory of the Brazilian physician is correct, the 
deduction ensues that the application of quinine for the relief of malarial 
patients is of no avail so long as the parasite, the new etiologic factor in 
the disease, retains lodgement. The investigations of Sehrwald seem 
to indicate that persons who had suffered from malaria to the degree 
of becoming anemic and debilitated, were restored to perfect health 
after the elimination of the ankylostoma duodenale. 



A WORD TO THE WISE. 

The enthusiasm incident to successful organization has caused 
some State Medical Societies to arrogate greater authority than can be 
either advantageously or conveniently exercised. The bulletins estab- 
lished to promote organization have sadly neglected proper function 
and exceeded rightful scope, ostensibly for the purpose of coralling 
every medical paper in sight and thereby forcing independent journalism 
from the field. In certain quarters, however, the folly of striving to 
conduct general journals has been realized, as for instance in Missouri 
— where people have to be shown — ^and the following change was 
recently instituted: "The association journal is to be hereafter more 
completely devoted to organization ^and unifying the association ; it is 
not to be the organ of any county society, and will serve the best 
interests of each and all. Doctor Edward J. Goodwin, of Saint Louis, 
will be its managing editor, a choice which assures conservative and 
wise conduct for a valuable organ." 



CONTEMPORARY. 



PHYSICIANS AND PHILOSOPHERS. 

[PROFBSSOR CHARLBS WILLIAM SUPRR, OF OHIO UNIVBRSITY, IN POPULAR SCIBNCB MONTHLY.] 

{S2ontinued from pagt 236.) 

Both medical science and philosophy, though not metaphysics, had 
run their course by the time the Alexandrian era opened. A not incon- 
siderable number of new facts were collected in Alexandria, but the 
ability or the will to arrange them into an orderly system was lacking ; 
at least we must adopt this view with the scant evidence to the contrary 
before us. For more than a thousand years the one question asked 



328 EBITORIAL COMMENT. 

was not, What does nature say? What are the facts in the case? but, 
What does the master say? Beginning with the first Christian cen- 
turies, Europe and western Asia more and more became organized into 
a society to suppress the increase of knowledge. It would not be easy 
to say in which century this organization did the most eflFective work, 
though there is no doubt that its most effective instrument was the 
inquisition. As everybody knows, it was not theology alone that was 
conservative; law and medicine were equally so. Goethe pays his 
respects to this attitude of mind when he says in Faust: 

Hear, therefore, one alone, for that is best, in sooth, 
And simply take your master's words for truth. 
On words let your attention center! 
Then through the safest guide you'll enter 
The temple-halls of certainty. 

And again : 

fcip Preoarc beforehand well your part 

pflpiip.-r * With paragraphs all got by heart, 
^i^***^ So you can better watch and look 

That naught is said but what is in the book : 

Yet in this writing as unwearied be l 

As did the Holy Ghost dictate to thee. 

This conservatism was a characteristic of the times ; the Protestant 
revolution was hardly more than the beginning of a struggle for eman- 
cipation in a single direction. It did not enlarge the intellectual horizon 
of the lawyer or the physician. There is much evidence to show that 
with the rise of the belief in witchcraft, medical science, using the term 
in a very loose sense, received a distinct check. What was the advan- 
tage of familiarizing one's self with the nature or usual progress of a 
disease if its course was constantly liable to be interrupted by the will 
of some malevolent being possessed of supernatural power? What was 
to be gained by administering remedies that might at any time be ren- 
dered nugatory by the same demoniacal interference? Those who 
embraced the new faith promulgated by Luther were in some respects 
worse off than those who clung to the old religion. While Catholics 
and Protestants alike believed in witches and other agents of the devil, 
the former had also their saints and the Virgin, to whom they could 
appeal in time of temptation and distress and who were rarely appealed 
to in vain. For the latter, Satan and his emissaries were no less real ; 
but he had given up his faith in the efficacy of the intercession of the 
saints and the Virgin. His only resource, therefore, was to protect 
himself as best he might by dealing mercilessly with those who had 
anything to do with the black art. 

The late Herbert Spencer is said to have reached the conclusion 
toward the close of his life that man is not a rational being. One can 
hardly help subscribing to this creed when he learns the attitude of the 
public toward medical practice. We can understand why there should 
be a great deal of hazy thinking in matters of law and theology, since 



PHYSICIANS AND PHILOSOPHERS. 329 

they have to do with problems that are at best more or less abstract. 
But why the public should willfully shut its eyes to practical benefits 
in every-day matters, matters that so vitally concern its life and health, 
is hard to understand. Yet it is no harder to understand than why a 
stone will not of itself roll up hill. We can only realize this mental 
asphyxiation in the face of overwhelming evidence. It is explicable 
only from the standpoint of the universal belief in the utter powerless- 
ness of man in the presence of the spirits that surround him and dwell 
within him. Though the scriptures have much to say about casting 
out devils, the belief in them is human rather than Christian, since it is 
found among all the peoples of the globe, except among that small class 
who may be called rationalists; or who, if not themselves entitled to 
this designation, have inherited a rationalistic creed; for a rationalist 
is simply one who refuses to believe anything except on such evidence 
as his reason approves. 

There are grounds for believing that Aristotle dissected human 
bodies; at least on no other grounds can his correct information with 
regard to certain points in anatomy be explained. But for prudential 
reasons he did not deem it wise to make public how this knowledge was 
obtained. Salerno seems to have been the first medical school in Italy 
outside of Spain, that is, the earliest in charge of Christians, and the 
probability is that its origin has some connection with the Arab dom- 
ination. Bologna came into prominence in the thirteenth century and 
retained its preeminence for a long time. Here we have some definite 
statements by Mondino that he dissected several cadavers. But his 
writings also furnish the proof that he was not able to emancipate him- 
seif wholly from the authority of Galen and the Arabians. For some 
reason there were fewer obstacles In the way of the anatomist in Italy 
than in any other country in Europe ; Berenger of Carpi is said to have 
performed more than a hundred dissections. In Italy, too, we meet 
with a number of names that are immortalized by their discoveries in 
the human body. The chief merit of Vesalius lies in the fact that he 
clearly recognized for the first time many of the errors that had come 
into current belief by the authority of Galen.. 

Hippocrates, Celsus, Galen, these three names sum up the science 
of ancient medicine; but the greatest of these is Hippocrates. It is 
perhaps not putting the case too strong if we say that they embrace 
substantially the entire healing art until not much over a century ago. 
The medical works of these three authors were printed in Italy before 
the end of the fifteenth century in Latin translations from the Arabic. 
This is striking testimony to the completeness of the rupture between 
ancient Greece and dawning era of modern times. When these Latin 
translations from the Arabic were made is not known ; but it is known 
that they were very imperfect and that they were as blindly followed 
as were the writings of Aristotle. Galen's prestige was more due to 
his ambition and industry than to his individual merit. The great mass 
of medical knowledge was still accessible in manuscripts. This he 



330 EDITORIAL COMMENT. 

carefully examined, and wrote comments upon much of it with remark- 
able discrimination for his age. Like Aristotle he would have been the 
first to repudiate the utterly senseless homage paid to his writings. 
One cannot read the works of Hippocrates without being impressed 
with the extraordinary acumen of the man. Much that now passes 
current under his name is doubtless not genuine, in the strict sense 
of the word; but is at least evidence to the prestige of the master's 
name. The thinker constantly appears along with the practitioner. 
And we must always keep in mind that chemistry was unknown and 
the microscope nonexistant. He tells us, among other things, that 
rain water is the purest, while ice and snow water are the worst for all 
purposes. He had carefully noted the radical differences between the 
people of Asia and of Europe, so far as he knew these parts of the 
world. What he says concerns the physician but little, the philosopher 
a great deal. He directly contravenes popular belief when he tells his 
readers more than once that there is no such thing as a sacred disease ; 
that no disorder is sent by a god, and that all ailments are due to 
natural causes. How heterodox this was may be seen by any one who 
reads the first book of the Iliad, where Apollo is represented as having 
sent a pestilence upon the Greek host. In his discourse on ancient 
medicine — a singular title for a book written more than four centuries 
before t